RC 


T5 
liiulogy  1 


UC-NRLF 


B    3    lib    3fil 


en 


•X) 
00 


o 


MENTAL   DISORDERS 


Briefly  Described  and  Classified 


WITH 


A  Few  Remarks  on  Treatment 
and  Prevention 


By  CHARLES  B.  THOMPSON,    M.   D. 

Medical  Director  of  the  Mental  Hygiene  Societj'  of  Maryland 
Assistant  Dispensary  Psychiatrist  The  Phipps  Psychiatric  Clinic,  The  Johns  Hopkins  Hospital 


Baltimore 

WARWICK  ^'  YORK,  Inc. 

1920 


-V- '  •-••  v*:  ;  ••'    .•,'./  file  -^v, 


£J 


-t..      -V 


CONTENTS 


THE  TWO  TYPES   OF   MENTAL   DISORDERS 

A.  Those  associated  with  physical  or  chemical  injury  to  brain  tissue 5 

B.  Those  which  seem  to  exist  only  on  psychological  bases 5 

A.     MENTAL    DISORDERS   WITH     DEFINITE    INJURY     TO     BRAIN 

TISSUE 

L     PHYSICAL  INJURY— ORGANIC  BRAIN  DISEASE— Loss  of  Tissue.  5 

1.  General  Paresis .^ 5 

2.  Traumatic    Disorders <r' 

a.  Delirium  immediately  following  the  accident 8 

b.  Various  degrees  of  loss  of  memory r- 8 

c.  Conditions  due  to  localized  injury S 

d.  Post-traumatic    constitution T 8 

e.  Terminal  deterioration S 

3.  Senile  Psychosis : 8 

4.  Arteriosclerotic  Ps3-chosis 9 

5.  Localized  Injury _ 9 

6.  Diffuse  Nervous  Diseases 0 

a.  Tuberculosis  of  the  brain r 9 

b.  Tuberculous    Meningitis .  .' 9 

c.  Multiple   Sclerosis 10 

d.  Huntington's    Chorea 10 

7.  Brain  Tumor 10 

8.  Brain   Syphilis 10 

9.  Brain    Abscess.  .• 10 

TO.     "Organic   Brain  Disease" 10 

11.  Idiocy  and  Feeble-Mindedness   (congenital  or  due  to  injury  at  birth)  10 

12.  Constitutional    Inferiority 11 

J  [.     CHEMICAL  OR  TOXIC  INJURY— Injury  by  Poisoning 1 1 

1.  Alcoholic  Psychoses 1 1 

a.  Pathological  Intoxication 11 

b.  Delirium  Tremens i- 

c.  Acute    Hallucinosis ~. . . . .  i-i 

d.  Alcoholic    Constitution 12 

e.  Alcoholic    Paranoid    States i- 

f .  Korsakoff's  Ps3'chosis 13 

2.  Drug  Psychoses , I3 

a.  Drug  Habits 13 

b.  Accidental   Poisoning  by  Drugs 14 

c.  Trade  Poisoning  by  Drugs 14 

d.  Illuminating  Gas   Poisoning 14 

e.  Food  Poisoning , 14 

2 


CONTEXTS  CONTINUED  3 

3.     Toxic-Infective-Exhaustive  Reaction  Type 15 

a.  Febrile    (infection) 15 

Delirium 15 

Incidental  Depressions  in  the  course  of  certain  diseases 15 

b.  Tnxic-Exhaustive 16 

Uremic,  Diabetic,  or  Eclamptic  Disorders 16 

Thyroid    Disturbances 16 

c.  Exhaustive — Extreme  Lack  of  Sleep 16 

COMBINED  A.  AXD  B.  DISORDERS 

1.  Psychoses  of  Pregnancy 16 

Treatment 17 

Post  Partum  Psychoses 18 

2.  Epilepsy , 18 

B.     DISORDERS  EXPLICABLE  IX  PSYCHOLOCxICAL  TERMS 

How  Emotion  Guides  Behavior 20 

I.  THE  MARKED  MENTAL  DISORDERS. 22 

1.  Elation-Depression  Oscillation    (.Manic-Depressive   Psychosis) 22 

2.  Depressions  Other  than  of  Manic-Depressive  Group 25 

a.  That  caused  by  disease  (more  properh^  under  Toxic) 25 

b.  Depression  with  hallucinations. .  .  .^ 26 

c.  Depression  with  paranoid  trend 26 

d.  Agitaied   Depression 26 

3.  Atypical    Excitements 26 

■    4.     Paranoiia 2~ 

5.     Dementia    Precox . 28 

a.  Simple    Type 29 

b.  Hebephrenic 3^ 

c.  Catatonic 3 ' 

d.  Paranoid 3- 

Discussion  of  Development  of  Dementia  Precox 34 

II.  THE  NEUROSES  OR  "NERVOUSNESS",  OF  APPARENTLY  WELL 

PEOPLE 4' 

1.  Neurasthenia     A- 

2.  Psychasthenia     4'-' 

3.  Hysteria 4- 

4.  Anxiety    Neurosis 4- 

Discussion  of  Causes  of  Neuroses 43 

PRINCIPLES  OF  TREATMENT  OF  MENTAL  DISORDERS 44 

PRINCIPLES  OF  PREVENTION  OF  MENTAL  DISORDERS 47 

List  of  Four  References 48 


5032i»ti 


INTRODUCTION 

This  syllabus  has  been  written  in  response  to  the  growing  desire  for 
knowledge  in  Psychiatry.  The  method  pursued  has  been,  first,  to 
describe  the  common  disorders ;  second,  to  deduce  therefrom  a  few 
essential  principles  as  to  causation  and  treatment. 

It  may  perhaps  be  noted  that  the  subject  of  child  psychology,  except 
in  the  discussion  of  Dementia  Precox,  lias  not  been  touched  upon. 
Child  psychology  cannot  be  considered  a  thing  apart  from  adult  psy- 
chology. The  two  are  continuous  and  identical,  and  we  have  but  one. 
Human  Psychology.  The  earlier  phases  of  this  are  best  studied  through 
the  Freudian  literature  and  psycho-analysis.  These  show  that  the^ 
neuroses  and  many  of  the  psychoses  are  distortions  of  this  infantile 
mind  coming  into  contact  with  the  conditions  and  facts  of  everyday  life. 

I  would  suggest  that  this  pamphlet  be  used  as  far  as  possible  in  con- 
junction with  actual  observation  of  cases,  and  in  consultation  with  a 
trained  psychiatrist. 

All  classifications,  and  especially  this  one,  must  be  regarded  as  being- 
more  or  less  tentative,  but  while  not  final  they  enable  us  to  utilize  the 
definite  facts  which  are  already  known.-  If  this  outline  establishes  a 
few  landmarks  and  furthers  a  little  the  interest  in  its  field  it  will  have 
served  its  purpose. 

Baltimore,  Md.  C.  li.  'J\ 

April,  1920. 


MENTAL  DISORDERS 

^Icntal  disorders  fall  into  two  general  classes : 

A.  Mental  disoidcrs  in  'chicli  the  re  is  definite  injury  to  brain  tissue. 
Since  the  mind  is  dependent  on  the  hrain,  there  are  mental  changes  as 
a  consequence  of  the  injury  to  the  hrain  suhstance. 

B.  Mental  disorders  zehieJi  seem  to  be  explicable  entirely  on  a 
psychological  basis.  These  have  heen  called  emotional  disturhances, 
"functional  diseases,"  or  emotional  maladjustments. 

The  details  of  Class  A.  -are  given  first.  Xo  mental  disorder  can 
be  assumed  to  exist  upon  purely  a  psychological  basis  until  the  possi- 
bilities of  physical  illness  have  been  eliminated  by  all  the  tests  known 
to  medicine. 

A.     :\IEXTAL   DISORDERS   WITH    DEFINITE    INJURY    TO 

BRAIN  TISSUE 

These  are  of  two  kinds  according  as  the  injury  is 

(  I  )  pJiysieal.  with  absolute  loss  of  brain  tissue,  forming  the  Organic 
Psychoses.  The  injury  may  have  been  caused  by  infection,  hemorrhage, 
accident,  arteriosclerosis,  or  some  similar  agent.  These  mental  changes 
are  permanent. 

(2)  chemical  from  poisons — called  toxines — floating  in  the  blood, 
hence  acting  on  the  brain  tissue,  and  causing  brain  changes  and  imental 
symptoms,  forming  the  Toxic  Psychoses.  The  toxine  may  be  an  actual 
poison  which  has  been  taken  into  the  body,  such  as  an  overdose  of 
alcohol  or  opium,  or  it  may  arise  from  infection  in  the  body,  or  be 
generated  by  a  diseased  organ  within  the  body.  These  Psychoses  may 
be  permanent  or  only  transitor}'. 

I.  Psychoses  ^^'lTH  Loss  of  Braix  Tissue. 

These  have  certain  general  characteristics,  Memory  Defect — there 
are  absolute  "holes  in  the  memorv"  as  if  certain  events  or  vears  had 
never  happened ;  great  A'ariation  in  Judgment — this  is  good  one  time, 
poor  another ;  a  very  obvious  Loss  of  Ability  to  Grasp  Situations ; 
sometimes  attacks  resembling  epilepsy  in  appearance. 

I.       GENERAL   PARESIS. 

This  is  characterized  by  a  deterioration  of  the  mind  and  character 
due  to  a  progressive  damage  to  brain  tissue,  the  cause  being  syphilis  of 
the  brain. 

A  formerly  staid  member  of  the  community  suddenly  or  gradually 
becomes  careless  in  his  appearance,  in  his  behavior,  and  in  his  business 
habits. 

There   are   gross   lapses    of   memory,   the   most    critical   things   are 


6  MliNTAt  DISORDERS 

jovially  forgotten.  Important  business  engagements  are  made  and 
not  kept,  large  deals  are  let  go  hang  in  the  imost  haphazard  fashion 
or  other  large  deals  are  undertaken  without  judgment.  His  judgment 
is  so  impaired  that  he  has  delusions  of  grandeur,  (grandiose  ideas  or 
Megalomania),  everything  is  described  by  him  in  heroic  style — he 
runs  several  hundred  miles  in  a  half  hour;  his  friends  and  relatives 
are  the  monarchs  of  the  various  countries  throughout  the  world ;  he  is 
building  a  bridge  to  Europe ;  possesses  millions  and  millions  of  dol- 
lars, etc.  At  the  same  time  he  shows  tremendous  gaps  of  memory, 
particularly  of  past  events,  leaving  out  periods  of  lo  or  15  years  in 
giving  a  story  of  his  life,  and  being  unable  to  make  any  but  the  simplest 
calculations. 

And  the  patient  seems  utterly  oblivious  to  these  as  to  all  his  other 
mistakes,  in  fact,  he  is  highly  pleased  with  his  performance.  His 
mood  is  generally  that  of  euphoria  or  exaggerated  self-complacency, 
the  patient  seeming  to  have  no  insight  as  to  the  pitifully  small  extent 
of  his  real  capacities. 

Further,  there  is  a  characteristic  slurring  speech  with  repetition  of 
syllables,  sometimes  of  words,  such  as  "Third  Artililerary  Brigrgrade" 
or  "Hypotapamus,  hypotapamus,  hypotapamus."  There  is  often  a 
great  tremor  of  hands,  and  tremulous  gait.  Spinal  fluid  taken  by 
lumbar  puncture  shows  characteristic  luetic  changes  (positive  Wasser- 
mann,  positive  gold  chloride  test,  high  cell  count).  Blood  Wassermann 
is  often  positive.  In  the  later  stages  of  the  disease  the  patient  deteri- 
orates to  such  an  extent  that  only  the  vegetative  functions  remain.  He 
can  but  eat  and  sleep.  There  may  be  convulsions.  Though  as  a  rule 
the  patient  is  unaware  of  his  real  condition,  sometimes  his  insight  is 
very  clear  and  he  is  most  distressed  at  watching  his  own  mental  dis- 
integration. .  • 

The  most  dangerous  point  of  the  disease  is  that  with  this  loss  of 
memory  and  inefficiency,  there  are  combined  very  exaggerated  ideas  of 
his  own  prowess  and  ability,  so  that  the  many  complications  which  may 
arise  when  this  disease  comes  upon  a  man  in  a  responsible  position, 
engaged  in  many  important  business  dealings,  may  be  tremendous. 
It  is  highly  important  to  detect,  if  possible,  an  incipient  case. 

The  onset  is  not  always  as  sudden  and  as  remarkable  as  given  above ; 
it  may,  on  the  contrary,  be  quite  gradual  and  insidious.  ]\Iany  incipient 
cases  of  General  Paresis  have  gone  undiagnosed  for  a  time,  or  have 
been  considered  to  be  mild  excitement  or  depression.  Diagnosis  is  im- 
portant because  of  the  prognosis  which  in  General  Paresis  is  always 
very  gloomy,  at  least  until  further  advances  in  the  methods  of  medica- 
tion have  been  worked  out. 

As  early  symptoms  there  imay  be  merely  change  in  disposition — a 
usually  tidy  person  may  become  careless  as  to  his  general  appearance ; 


MKNTAL  DISORDERS  7 

occasional  odd  behavior — grossly  inappropriate  remarks  may  suddenly 
make  their  appearance ;  lapses  of  memory,  or  perhaps  a  sudden  and 
transitory  loss  of  consciousness  may  take  place.  The  patient  may 
become  somewhat  restless,  or  somewhat  elated.  A  more  careful  test  of 
memory,  especially  of  retention,  would  show  defects.  There  may 
often  be  a  beginning  speech  defect  in  test  phrases ;  there  may  be  tremor 
of  facial  muscles  or  of  the  hands,  or  a  beginning  tremulous,  uncertain 
gait.  Lumbar  puncture  here  is  conclusive,  the  characteristics  being  a 
high  cell  count,  strongly  positive  globulin  test,  positive  Wassermann 
and  gold  chloride  test. 

GENERAL    PARESIS 

The  patient  was  a  young  woman  of  26  who  had  been  arrested  for  shop-lifting, 
having  jusi  helped  herself  right  and  left  wherever  her  fancy  pleased.  Moreover, 
she  had  placed  orders  in  various  other  stores  for  five  hundred  shirts,  dozens  of 
pairs  of  stockings,  etc.    Her  husband  was  a  small  Jewish  tailor. 

The  woman  appeared  to  be  a  young  Jewish  woman  of  a1)out  28,  who  was  quite 
euphoiic  and  had  a  very  lackadaisical  manner.  She  talked  very  freely  about 
herself,  husband,  etc.  Said  that  she  is  an  actress  at  the  Hippodrome  in  the 
afternoons  and  evenings,  also  a  waitress  at  Childs'  in  the  mornings,  and  makes, 
with  her  husband,  -a  great  deal  of  money.  Speaks  of  having  paid  $500  for  a 
brooch,  also  $500  for  a  necklace,  $300  for  an  automobile,  etc.,  etc.  Says  that 
she  has  six  children,  and  is  supposed  to  have  none.  Says  that  her  husband, 
who  is  a  tailor,  will  make  the  doctor  a  suit  of  clothes  for  a  Christmas  present. 
She  is  also  going  to  buy  him  a  motorcycle  with  a  sidecar,  and  he  can  take  her 
out  in  it.  She  pulls  out  a  blue  silk  handkerchief  which  she  says  her  "gentle- 
man friend,"  an  Italian  fellow,  gave  her.  Tells  the  doctor  she  will  give  it  to 
him  and  throws  it  on  his  desk.  She  talks  of  a  dancing  academy  which  she  and 
her  husband  are  going  to  establish  on  Greenmount  .Vve.,  and  says  that  she 
bets  the  doctor  will  enjoy  coming  there.  She  spoke  of  having  nine  nieces, 
all  of  whom  are  going  to  marry  well — doctors,  engineers,  etc. — and  they  are 
going  to  have  nine  weddings,  all  at  the  Emerson  Hotel. 

Her  memory  for  dates  is  quite  poor.  Says  she  was  married  at  14.  has  been 
married  15  years,  and  is  now  26.  Does  not  see  her  error.  Says  her  oldest  child 
is  14,  was  born  four  years  after  marriage,  there  having  been  two  still-births 
before  that  time. 

ADVANCED    CASE    OF     GENERAL     PARESIS 

The  patient  was  a  man  of  48  who  had  been  unable  to  work  for  a  year.  When 
first  seen  he  was  standing  in  his  store  diilly  trying  to  fasten  his  cuff,  but  being 
prevented  by  his  great  tremor.  He  had  the  typical  greasy  yellow  complexion, 
and  talked  with  scanning  speech. 

His  first  remark  was,  "I  ain't  sick."  He  had  little  memory  for  past  events ; 
did  not  know  the  name  of  the  street  in  front  of  his  store,  and  finally  gave  the 
name  of  one  in  another  part  of  town.     He  gave  his  age  as  42. 

He  frequently  would  wander  out  into  the  town,  and  be  unable  to  find  his 
way  back. 

Throughout  the  interview  he  kept  repeating,  ''I  ain't  sick.  I  got  hundred 
dollar  Liberty  Bond.     I  ain't  sick.     I  got  hundred  dollar  Liberty  Bond." 


8  -  -MENT^\L  DISORDERS 

2.       IRAUMATIC      DISORDERS.      (TRAUMA — INJURY),      THOSK      CAUSED      V,Y 

ACCIDENTAL   IX^URY  TO  BRAIN. 

These  do  not  follow  even'  accident  by  any  means.  As  a  rule  thev 
take  place  only  when  the  accident  has  been  so  severe  that  the  patient 
remains  unconscious  for  hours  or  even  days.  Any  one  of  the  foilownig" 
may  come  separately,  or  it  may  appear  combined  with  one  of  the  otner 
types : 

a-.  Dcliriiini  iiuuiediatcly  follozving  the  accident,  i.  e.,  loss  of  knowl- 
edge of  the  time  and  place — the  patient  has  no  idea  as  to  the  date  or 
the  situation,  whether  hospital  or  home,  he  may  think  it  a  ship,  fort, 
wqrkshop,  etc.    He  may  possibly  have  hallucinations. 

The  previous  presence  of  alcoholism  or  senility  may  add  coloring 
or  duration  to  the  picture. 

h.  Various  degrees  of  loss  of  Jiiemory  combined  with  apparently 
hysterical  condition. 

c.  Conditions  due  to  local i.ced  iiijury  to  one  part  of  the  brain,  such 
as  aphasia,  with  injury  to  speech  mechanism,  the  patient  may  lose 
the  ability  to  write  or  read  ;  or  asymbolia,  wherein  he  loses  all  power 
of  communication  even  by  signs,  etc.    These  may  occur  at  once  or  they 

■may  appear  later  as  residual  conditions. 

d.  Posi-trauniatic  constitution,  easily  affected  by  alcohol,  grippe, 
fatigue,  etc.,  with  headaches  or  tendency  to  sudden  and  unwarranted 
outbursts  of  temper.  Possibly  with  paranoid  development  (delusions 
of  persecution  or  grandeur),  or  depression. 

e.  Conditions  of  deterioration  coming  considerably  later  from  pro- 
gressive changes  in  injured  tissue,  characterized  by  loss  of  memory,  and 
loss  of  efficiency  and  of  mental  activity. 

The  patient  before  his  accident  was  a  telegraph  hneman.     He  is  aged  27. 

He  left  school  at  the  age  of  13,  in  the  4th  grade. 

He  had  always  been  a  hard  worker. 

On  July  3,  1913,  he  fell  25  feet  to  the  ground,  landing  on  his  left  side.  He 
was  unconscious  for  12  days.     He  remembers  nothing  until  August,  1913. 

Now  he  does  not  remember  having  climbed  the  pole,  and  remembers  nothing 
concerning  two  to  three  days  before  the  accident,  (retrograde  amnesia).  He 
forgets  events  which  occurred  during  the  two  weeks  after  he  regained  con- 
sciousness,   (anterograde  anmesia). 

Since  the  accident  there  has  been,  according  to  the  account  of  his  relatives. 
a  marked  change  in  his  efficiency  and  disposition.  As  seen  in  the  hospital  he 
cannot  remember  what  he  did  during  the  just  previous  hour  (going  to  town  in  a 
carriage)  ;  he  has  difficulty  in  recognizing  people;  difficulty  in  recognizing  voices 
of  friends  over  the  telephone:  his  memory  is  impaired;  he  gets  tired  easily;  he 
suffers  from  loss  of  confidence  in  himself;  he  has  a  violent  temper  and  is  easily 
irritated  and  restless ;  he  considers  his  symptoms  chiefly  due  to  hospital  life. 
Many  references  to  end  it  all  by  suicide.  Finally  he  left  the  hospital  dissatisfied 
and  irritated. 

3.      SENILE    PSYCHOSIS. 
This   occurs,   of   course,   generally   in   the   aged,   though   there   aie 
some  cases  of  premature  senility  as  in  cases  of  arteriosclerosis.     The 
symptoms  are  forgetfulness,  particularly  of  very  recent  events,  con 


MENTAL  DISORDERS  9 

trasted  at  times  with  a  surprisingly  clear  memory  of  childhood  events  ; 
a  poor  grasp  of  situations  and  indecision.  Also  the  patient  is  particu- 
larly apt  to  get  confused  when  called  upon  to  transmit  a  message ;  or 
when  he  is  obliged  to  act  quickly  and  decisively,  as,  for  instance,  in 
crossing  the  street.  If  given  abundance  of  time,  however,  he  may 
get  along  satisfactorily.  The  patient  is  liable  to  sudden  attack's  of  agi- 
tation or  restlessness,  especially  at  night  when  he  may  be  overcome  by  a 
desire  to  get  up  and  go  somewhere,  not  knowing  where  or  why,  with 
afterwards  entire  forgetfulness  of  these  attacks.  Delirium  may 
occur. 

The  patient  is  a  laborer  of  59.  Whereas  he  had  not  worked  for  one  year 
before  the  examination,  he  expressed  himself  as  having  been  regularly  in  the 
employ  of  Swift  &  Co.,  and  having  worked  the  day  before,  or  not  longer  than 
a  week  before.  That  he  had  injured  his  foot  then  in  an  accident  (this  had  been 
months  before).  He  stated  that  he  received  $15  a  week,  but  to  account  for  his 
not  having  any  money  in  his  pockets,  he  accused  his  daughter,  at  whose  house 
he  lived,  of  being  in  the  habit  of  picking  his  pockets  while  he  was  asleep.  He  got 
rather  excited  over  this. 

He  was  mistaken  as  to  the  date,  said  it  was  early  in  January  when  it  was 
February  3rd,  but  was  oriented  for  place  and  person.  He  was  liable  to  extreme 
outbursts  of  temper,  getting  extremely  angry  with  his  daughter  over  very  small 
incidents.  At  night  he  would  often  get  up  and  wander  about  the  house : 
sometimes,  he  would  turn  on  the  gas  without  lighting"  it.  apparently  not 
realizing  what  he  was  doing,  and  go  back  to  bed  again  leaving  the  gas  turned  on. 

4.       ARTERIOSCLEROTIC   PSYCHOSIS. 

As  a  rule,  this  otuiffsin  men  or  women  of  advanced  age,  but  it  may 
occur  in  middle-aged  or  young  people  as  a  result  of  arteriosclerosis, 
and  may  cause  premature  senility.  The  symptoms,  which  may  appear 
singly  or  in  any  sort  of  combination  are  a  tendency  to  become  easily 
irritated  or  moved  to  tears ;  loss  of  memory  and  a  general  dulling  of 
acuteness ;  headache  and  ringing  in  the  ears ;  signs  of  localized 
injury,  such  as  aphasia;  attacks  of  confusion  with  loss  of  sense  of  the 
time  and  place.  At  times  there  is  a  placid,  contented  or  rather  happy 
frame  of  mind.  As  an  occasional,  though  striking,  symptom,  the 
patient  will  fall  asleep  at  all  other  odd  moments,  often  in  the  middle 
of  a  conversation.  There  are  other  signs  of  arteriosclerosis,  tingling  or 
numbness  in  the  hands  or  feet. 

5.      VARIOUS  STATES  OF  MIND  DEPENDING  ON  LOCAL  INJURIES 

WITH  Aphasia,  Asymbolia,  etc. 

6.      DIFFUSE    NERVOUS   DISEASES. 

a.     Tuberculosis  of  brain. 
This  is  marked  by  dullness,  defect  of  judgment  and  memory,  dis- 
orientation,  stupor.      Often    a    demonstrable    tuberculous    lesion    else- 
where in  the  body  as  a  primary  focus  from  which  the  brain  injury  has 
developed. 

b.     Tuberculous  uieniiigitis. 
The  signs  are  excitement  followed  by  lethargy  with  all   the  signs 
of  meningitis,  characteristic  spinal  fluid. 


•  10  ~  MENTAL   DISORDERS 

c.     Multiple  Sclerosis. 
Symptoms  are  apathy,  combined  with  deterioration. 

The  patient,  a  man  of  38,  had  been  a  laborer,  but  had  finally  been  prevented 
from  working  by  his  progressive  paralysis  which  showed  the  typical  signs  ot  the 
disease.  Becoming  finally  bedridden  and  nearly  helpless,  and  showing  some 
mental  changes,  he  was  brought  to  the  hospital. 

On  the  ward  he  showed  great  memory  defect,  and  could  give  scarcely  any 
dates  of  events  in  his  life.  He  could  place  the  date  of  his  birth  and  marriage, 
but  had  forgotten  the  dates  of  any  of  the  positions  he  had  held.  Because  of  this 
defective  memory,  he  could  not  learn  to  play  checkers,  he  did  not  care  to  read. 
And  he  could  only  learn  the  simplest  basket  work.  Alost  of  his  activity  con- 
sisted in  just  looking  about  him  at  the  other  patients  and  at  the  nurses,  and  in 
feeding  himself  at  meal  times.  Though  he  could  just  barely  move  his  hands 
and  otherwise  had  to  be  moved  and  taken  care  of,  nevertheless  he  was  always 
cheerful,  expressed  himself  as  feeling  well,  and  was  certain  of  recovery. 

d.     Huntington  s  Chorea. 

Progressive   loss    of   efficiency    going   over   to   dementia,    combined 

with   constant   large   choreiform   movements.      May   show   hereditary 

tendency. 

7,       BRAIN   TUMOR. 

Dullness,  with  loss  of  memory  and  efficiency.  May  be  convulsions. 
Placid,  contented  type  usually.     May  get  excited,  delirious  state. 

8.       BRAIN  SYPHILIS. 

This  is  differentiated  from  General  Paresis  in  that  the  process  seems 
more  localized.  The  symptoms  are  confusion,  or  a  delirious  state, 
auditory  and  visual  hallucinations,  memory  defect  for  recent  events. 
Judgment,  as  a  rule,  good.  The  insight  is  present,  and  the  patients  do- 
not  tend  to  untidiness  and  delapidation,  as  do  the  General  Paretics. 
Further  symptoms  are  headache,  possibly  focal  symptoms,  such  as 
paralysis ;  cranial  nerve  involvement  giving  vertigo,  deafness,  optic 
nerve  changes,  etc.     Prognosis  is  much  better  than  in  General  Paresis. 

9.       BRAIN  ABSCESS. 

Signs  of  infection  plus  those  of  organic  brain  disease,  with  or  with- 
out focal  symptoms. 

10.       ''organic  BRAIN  DISEASE.'' 

Cases  in  which  no  more  definite  diagnosis  has  been  reached.  ^lemory 
defect,  variation  in  judgment,  possibly  epileptiform  attacks.  Really 
covers  the  whole  group. 

II.       IDIOCY  AND  FEEBLE-MINDEDNESS. 

Also  called  "arrested  development."  The  causes  are  heredity  or 
birth  injuries  to  the  brain.  It  is  a  question  if  these  disorders  should 
properly  be  classified  here  inasmuch  as  they  are  due  to  incomplete  de- 
velopment of  the  brain,  i.  e.,  to  brain  absence,  not  brain  injury. 

In  these  folk  the  brain  develops  only  incompletely,  consequently 
there  is  every  degree  of  lack  of  mental  development  to  correspond. 
Thus  we  have  the  idiots  who  are  little  above  the  beast,  make  uncouth 
noises,  have  no  understanding,  can  take  no  care  of  themselves ; 
imbeciles,  a  little  bit  higher  but  not  able  to  make  a  living,  who  have  a 


MENTAL   I >ISORDI;KS  II 

mentality  ccjnivaler.t  to  that  of  a  child  between  three  and  eight  years 
of  age;  morons,  still  higher  but  still  of  subnormal  mentality,  namelv 
that  of  a  child  of  eight  to  twelve  years  of  age. 

It  is  quite  evident  that  people  who  are  thus  Feeble-minded  or 
Mentally  Defective  can  never  have  the  same  sense  of  responsibility, 
judgment,  memory  or  efficiency  as  a  normal  person  of  the  same  age. 
Yet  they  are  still  allowed  at  large  because  they  have  "always  been  that 
way,"  and  they  work  untold  harm,  having  to  be  always  supported  by 
others,  raising  large  families  of  the  same  shiftless  kind,  frequently 
turning  to  crime  for  a  livelihood. 

A  large  part  of  the  daily  work  of  the  police  force  and  jails  is 
taken  up  with  these  mentally  defective  and  hence  irresponsible  crimi- 
nals. Their  irresponsibility  and  immorality  and  illegitimacy  cause 
them  to  be  an  ever  growing  menace.  Many  diseased  prostitutes  are  re- 
cruited from  this  class. 

12.      CONSTITUTIONAL   INFERIORITY. 

May  or  may  not  be  allied  to  above.  The  old-fashioned  term  "atavist" 
would  come  under  this  caption ;  also  the  typical  "bad  egg''  or  "black 
sheep"  of  the  family.  Applied  to  those  from  whose  heredity  and  social 
status  one  would  expect  much,  but  who  really  seem  lacking  in  moral 
and  ethical  sensibilities,  and  commit  all  manner  of  indiscretions,  even 
crimes.  This  classification  is  often  used  to  include  the  feeble-minded  as 
well. 

The  patient,  who  was  a  young  man  of  good  family,  aged  23,  was  said  by  his 
father  always  to  have  been  "slow"  in  school,  and  in  fact  never  had  passed  the 
sixth  grade,  leaving  at  the  age  of  16.  He  had  always  been  different  from  his 
brothers  and  from  the  rest  of  the  family  who  were  successful  financiers  and 
factory  owners.  Moreover,  he  was  headstrong  and  self-willed  and  hostile  to 
advice,  but  could  never  make  his  own  living. 

At  18  he  was  sent  South  to  work  in  a  small  town,  but  here  he  would  con- 
tinuall}^  get  into  fights  with  the  men  he  had  to  deal  with  or  take  orders  from. 
Besides  he  w'ould  drink  and  try  to  shoot  up  the  town,  trying  to  subdue  all  the 
toughs  in  all  the  barrooms,  though  he  himself  was  only  the  size  of  a  weak  14- 
year-old  boy. 

From  here  he  was  brought  back  to  New  York.  He  gave  up  drinking  and 
became  a  street-corner  missionary.  But  he  "preached  Hell  so  hot"  that  the 
other  missionaries  had  him  removed. 

Then  he  married  a  girl  of  no  greater  mentality  than  himself,  and  was  moved 
off  to  a  nominal  job  in  another  city,  and  was  lost  sight  of. 

II.     Psychoses  of  Chemical  Injury  to  Brain  Tissue — or  Toxic 

Psychoses. 

I.    alcoholic  psychoses. 
Alcohol,  as  a  toxic  drug,  causes  so  many  and  such  characteristic  men- 
tal disorders  that  it  is  here  given  a  place  to  itself. 

(a)     Pathological  Intoxication 
Drunken  furor,  the  type  in  wdiich  a  man  fights,  beats  his  wife,  mur- 
ders, sets  fire  to  houses,  and  usually  has  no  memory  of  the  events 
afterwards. 


t2  MENTAL   DISORDERS 

The  patient,  a  man  of  42,  a  constant  drinker,  came  home  one  night  evidently 
very  drunk,  and  apparently  extremely  angry.  He  battered  and  pounded  on  the 
front  door  as  he  was  opening  it.  He  cursed  his  wife  and  called  her  obscene 
names.  He  picked  up  chairs  and  tables  and  smashed  the  other  furniture  and 
mirrors  with  them,  cursing  at  his  wife  the  while,  and  hurling  the  fragments  of 
the  furniture  at  his  children.  He  finally  upset  the  kitchen  stove,  bringing  down 
the  pipe,  and  scattering  the  cooking  vessels  and  the  supper  all  over  the  kitchen, 
roaring  all  sorts  of  broken  bits  of  drunken  obscenity. 

At  the  police  station  the  next  day,  he  apparently  had  no  memory  of  this 
event,  (amnesia).  He  said  that  he  remembered  coming  home,  but  nothing  more. 
He  indignantly  denied  the  violence,  and  told  the  judge  that,  although  he  drank 
frequently,  he"  rarely  became  intoxicated,  and  never  to  the  extent  described. 

(b)  DeUriuui   Tremens 

Generally  comes  after  the  patient  has  protracted  his  debauch  until 
he  can  no  longer  eat  or  sleep.  No  sleep  and  no  food  plus  alcohol  form 
a  disastrous  combination.  The  characteristics  are  loss  of  sense  of 
present  situation  and  persons;  and  at  the  same  time  the  patient 
imagines  he  sees  and  feels  rats,  mice,  snakes,  and  other  small  animals, 
generally  black,  crawling  all  about  the  floor,  the  bed,  the  walls,  himself. 
Often  he  is  haunted  by  faces  of  the  dead,  or  by  a  vision  of  the  devil. 
There  is  a  very  marked  appearance  of  fear — the. patient  seems  to  be 
in  the  most  horrible  mental  torture.  Recovery  generally  takes  place 
unless  other  complications  are  present. 

(c)  Acute  Hallucinosis 

Is  not  quite  the  same  as  delirium.  The  patient  knows  the  date, 
where  he  is  and  the  persons  about  him.  But  he  imagines  he  hears 
threatening  or  slandering  voices,  or  he  may  see  terrifying  sights — 
thinks  the  walls  are  falling  in  on  him  and  he  imust  hold  them  up ;  or  - 
that  a  team  of  horses  is  about  to  run  over  hhn,  etc.  Often  with  a 
sardonic  humor  that  causes  him  to  lavigh  at  the  same  minute  that  he 
is  shuddering  with  fear  (Galgen-humor)  ;  great  mental  anguish. 

The  whole  hospital  was  aroused  one  evening  by  the  sudden  yelling  of  a 
patient  who  had  just  come  in  the  previous  afternoon.  When  he  was  inter- 
viewed he  said  that  he  had  suddenly  seen  a  team  of  two  large,  black  horses 
which  were  just  about  to  run  over  him. 

He  was  an  alcoholic  and  had  just  begun  to  drink  more  heavily.  He  had  been 
having  similar  terrifying  hallucinations  for  the  past  two  days. 

(d)     Alcoholic  Constitution 

Habitual   alcoholics   become   increasingly   inefficient   and   unreliable. 

There  is  both  an  intellectual  and  an   ethical   deterioration.     Profuse 

promises  are  made  but  never  kept.     Forgetfulness  develops  often  with 

precocious  senility.    Also  suspicious  states  leading  over  to 

(e)  Alcoholic  Paranoid  States 
Ideas  of  jealousy,  persecution,  or  poisoniuii.  In  the  Delusions  of 
Jealousy,  a  man  will  accuse  his  wife  of  infidelity,  and  will  cling  to  this 
idea  in  spite  of  all  evidence  to  the  contrary,  openly  accusing  her  of 
going  with  other  men.  Not  infrequently  he  will  kill  his  wife  when  in 
such  a  disordered  mental  state.  ]\Iany  murders  have  been  committed 
on  this  delusion  as  a  basis. 


MKXTAL   DISORDERS  I3 

Delusions  of  Persecution  and  Poisoning 
The  patient  thinks  that  people  are  definitely  against  him  to  work  him 
injury-^much  like   the   usual    Paranoia,   except   that   here   there   is   a 
definite  alcoholic  history  leading  u])  to  the  psychosis. 

It  is  a  question  if  there  is  not  the  same  mechanism  underlying  both 
forms.  For  we  know  that  many  cases  of  Paranoia  represent  a  sub- 
merged homosexuality  which  is  denied  to  consciousness.  In  other 
words,  the  fear  is  born  of  repressed  desire.  xA.nd  the  chronic  alcoholic 
manifests  his  homosexuality  through  this  channel,  not  admitting  it  to 
further  consciousness,  and  not  being  able  to  ignore  it  completely. 

The  patient — a  chronic  carouser — had  been  married  several  years.  He  had 
three  children.  One  day  he  accompanied  liis  wife  to  a  doctor's  office,  and  there 
he  waited  in  an  outer  waiting  room  while  she  was  being  treated  for  varicose 
veins  of  the  leg.  As  the  doctor  and  patient's  w'ife  emerged  from  his  office,  the 
doctor  handed  her  her  garter.  The  patient  inferred  from  this  that  the  doctor 
had  had  improper  relations  with  her.  He  mentioned  this  many  times  to  her. 
Also,  he  implicated  the  parish  priest.  The  man  threatened  to  kill  his  wife  and  the 
doctor,  saying  that  he  felt  fully  justified  in  doing  so,  and  didn't  care  what  hap- 
pened to  himself. 

This  man.  also,  no  matter  what  jol)  he  held,  sooner  or  later  concluded  that 
some  certain  man  on  the  job  was  against  him  or  trying  to  get  him  discharged. 
Thus  both  forms  of  the  paranoid  or  delusional  state  were  found  in  one  patient. 
Abundant  evidences  of  submerged  or  unrecognized  homosexuality  were  shown 
in  this  man's  record. 

(f)     Korsakoff's  Psychosis 

Loss  of  sense  of  date  and  place,  great  "holes  in  memory,"  with  a 

compensatory  lying  to  fill  in.    Connected  with  nerve  injury,  causing  toe 

drop,  etc. 

FinalW  alcoholism  may  be  merely  a  symptom  of  some  other  under- 
lying mental  disorder.  A  psychopathic  patient  readily  takes  to  alcohol 
as  a  stimulant  or  refuge  in  a  state  of  depression,  or  in  case  of  inefiiciency 
such  as  Dementia  Precox  or  General  Paresis. 

2.      DRUG    PSYCHOSES. 

All  other  drugs  besides  alcohol  may  also  figure  in  drug  habits. 

(a)  Drug  habits  may  be  regarded  at  times  as  a  symptom  of  abnor- 
mal mental  states  or  of  an  abnormal  constitution.  The  craving  for  the 
drug  seems  to  outweigh  all  other  considerations  whether  of  duty, 
policy,  responsibility,  or  consideration  for  others.  This  results  in  ex- 
tremes of  unreliability  as  regards  his  outward  behavior.  Any  drug 
may  be  thus  used — opium,  morphine,  cocaine,  heroin,  chloral,  ether, 
chloroform. 

In  seeking  the  efifect  of  these  drugs,  the  patient  seems  to  be  trying 
to  escape  from  unpleasant  thoughts  or  situations  of  strain  which  trou- 
ble him  in  moments  of  introspection,  or  which  seem  to  hover  on  the 
margin  of  consciousness.  These  painful  ideas  multiply  as  his  dissipa- 
tions continue,  so  that  to  the  unpleasant  thoughts  or  mental  conflicts 
which  he  originally  sought  to  escape,  are  added  the  consciousness  of 


14  MENT-AL   DISORDERS 

responsibilties  shirked,  promises  broken,  friendships  violated,  dutiei^ 
demanding  to  be  met.  In  short,  he  has  beset  himself  with  added  dif- 
ficulties of  his  own  making  so  that  the  only  spot  of  pleasure  he  finds 
4s  this  drug  which  he  seeks  more  and  more. 

This  is  the  reason  why  the  habitual  drug  user  is  not  apt  to  give  up 
his  drug,  but  rather  to  become  ten  times  more  an  addict  with  each  dose 
he  takes.  The  psychological  side  of  alcoholism,  as  well  as  other  drug 
psychoses,  is  taken  up  in  more  advanced  works. 

The  *'habit"  is  rather  the  result  of  a  disordered  personality  which 
remains  constantly  out  of  adjustment,  and  represents  an  evasion  of  the 
conflict  in  his  mind,  or  living  a  lie.  The  addicts  are  hence  constitutional 
liars  and  their  consequent  undependability  and  ethical  deterioration 
are  only  to  be  expected.  Perhaps  the  individual  prefers  this  combi- 
nation to  the  discomfort  of  straightening  out  himself  and  the  whole 
situation. 

Many  interesting  stories  have  been  written  pertaining  to  the  state 
of  mind  of  these  drug  addicts.     (See  "Spy  Rock,"  by  Henry  \^an  Dyke, 
"Confessions  of  an  English  Opium  Eater,"  by  DeQuincey.) 
(bj     Conditions  resulting  from  accidental  poisoning  with  these  drugs. 

These  generally  show  comatose  conditions  (very  heavy,  deep  sleep 
from  which  the  patient  can  only  be  momentarily  aroused)  or  deliria — 
patient  loses  knowledge  of  where  he  is,  "wanders  in  his  mind,''  sees 
things,  hears  voices,  imagines  he  is  in  very  exciting  situations,  etc. 

fe)     Trade  poisojiiug 

This  may  be  accidental  poisoning,  acute  or  chronic,  with  manifesta- 
tions as  above — coma,  or  delirium,  or  excitement. 

(d)  Illuniinating  Gas  Poisoning 
Sometimes  when  a  very  great  amount  of  the  gas  has  been  inhaled, 
the  patient  after  resuscitation  is  found  to  have  great  inpairment  of 
memory.  Onl}-  the  most  simple  and  usual  things  are  remembered, 
thinking  is  largely  abolished,  and  ambition  gone.  The  mental  horizon 
seems  limited  to  the  gratification  of  hunger,  sex  desire,  and  desire  for 
sleep.  Physically  he  is  well  and  may  live  for  years  in  this  animal  state, 
the  brain  injury  being  permanent. 

(e)  TJiosc  caused  by  food 
The  most  comimon  is  the  caffeine  psychosis  in  its  mild  forms,  caused 
b\-  over-use  of  tea  or  coft'ee.  It  is  characterized  J)v  restlessness  and 
impatience,  desire  to  be  on  the  go.  dropping  one  half-finished  task  to 
take  up  a  new  one,  insomnia,  and  sensibility  to  slight  sounds  and  colors. 
In  fact  all  sensibilities  are  much  more  keen  and  react  to  much  finer 
stimuli  than  normally.  This  sensitization  is  the  reason  why  cafifeine, 
in  the  form  of  coffee  or  tea,  is  so  extensively  used.  It  makes  one  feel 
more  alive,  more  awake,  more  keen.  Fatigue  is  correspondingly 
quicker  in  arriving,  or  if  not,  then  when  it  does  arrive  is  felt  in  much 
greater  proportion. 


MENTAL   DISORDERS  1 5 

Also  to  be  mentioned  are  F^ellagra,  and 
Ergotism,   acute    poisoning — confusion    or   coma. 
Chronic  (from  ergot  growing  on  rye) — depression,  drowsiness  and 
weakness,  sometimes  convulsions. 

3.       Mi:.\T.\L  DISORDERS  COMING  FROM   FEVERS   (i.  e.   INFECTIONS),   FROM 

POISONS  OF  VARIOUS  DISEASES,  OR  FROM  EXHAUSTION-     THE 

TOXIC-INFECTIVE-EXHAUSTIVE   GROUP. 

These  are  usually  considered  together  because  the  results  of  infection 
are  due  to  toxine  and  exhaustion  also. 

(a)     From  fevers  and  Infections 
Commonest  is  delirium,  slight  lapse  from  normal;  surest  recovery. 
Disorientation  plus  hallucinations  are  the  characteristics  of  delirium. 

A  single  woman  of  34,  whose  past  history  shows  a  somewhat  labile  psychc- 
pathic  disposition  and  a  tendency  toward  slight  depression,  began  to  show  signs 
of  abdominal  involvement — pain  in  the  groin,  tenderness  over  right  lower 
quadrant,  septic  temperature,  and  sweats.  The  appendix  was  operated,  but  the 
signs  continued. 

Eleven  days  after  the  operation  she  l:;ecame  fretful  and  excited,  and  soon 
began  to  have  visual  hallucinations — thought  people  were  looking  through  the 
ceiling  at  her;  that  the  house  was  on  fire;  that  a  man  came  and  dragged  her 
about  by  the  hair  each  night.  , 

She  thought  the  hospital  was  her  home,  and  that  she  was  in  her  own  bed. 
She  gave  the  month  as  April,  whereas  it  w^as  January.  Immediately  on  examina- 
tion she  warned  the  doctor  that  there  were  people  standing  behind  him  to  kill 
him.  She  was  easily  recalled  by  a  word  or  two  from  these.  Hallucinations 
plus  disorientation  indicated  the  presence  of  Delirium. 

During  the  "Spanish  Flu,"  or  more  properly  Pandemic  Influenza, 
there  were  many  cases  of  mental  upset  wdiich  seemed  due  to  the  ex- 
treme virulence  of  the  toxine.  A  very  excited  form  of  delirium  was  a 
frequent  complication  of  the  disease. 

The  patient  was  quietly  lying  in  bed  on  the  hospital  porch  which  fortunately 
was  screened.  He  suddenly  jumped  up  and  yelled,  "Police,  police.  Send  a  police 
over  here."  To  the  crowd  who  immediately  assembled  in  the  street  outside,  he 
3'elled,  "They  are  trying  to  shanghai  me  here  and  send  me  away  on  a  ship.  Tve 
got  the  Spanish  Flu.     Send  a  police  here." 

Other  patients  would  get  up  and  try  to  wander  about  or  riui  out  of 
the  hospital,  not  knowing  where  they  were.  These  excited  cases 
usually  had  a  fatal  termination. 

Depression  and  fatiguabilitx'  seemed  to  be  a  common  result  of  the 
infection,  often  lasting  weeks.  After  the  pandemic  many  cases  were 
referred  for  examination  whose  disorder  was  said  to  have  been  caused 
by  the  Spanish  Influenza.  Certainlv  many  of  these  might  merely 
have  been  irupending  and  were  immediately  precipitated  by  the  infec- 
tion. Certainly,  also,  no  such  drastic  toxine  as  that  which  characterized 
the  severe  cases  of  the  "Flu"  would  leave  a  person  quite  unscarred. 

Depression  with  Fever  or  Infectious.  In  certain  cases  of  grippe  the 
patient  seems  to  have  delusions  of  persecution  and  to  think  he  or  she 
is  mistreated. 


l6  '  ,       MENTAL  DISORDERS 

Transitory  Memory  Defect  may  sometimes  result. 
A  Permanent  Memory  Defect  is  less  common  but  has  been  known 
to  follow  Typhoid  or  Scarlet  Fever. 

(b)  Toxic-B^'haustwe  Conditions,  no  fevers  present,  from  Uremia, 
Diabetes,  or  Eclampsia,  (toxic  condition  caused  by  pregnancy). 

Usually  is  just  a  deep  coma.  Or  there  may  be  delirium.  Or  accom- 
panied by  some  confusion.  There  may  be  great  restlessness  or  irri- 
tability ;  the  patient  may  wander  off  and  arrive  in  another  city  not 
knowing  where  or  who  he  is.  The  various  laboratory  tests  known  to 
medicine  will  serve  to  differentiate  and  diagnose  these  conditions. 

THYROID. 

Cretinism.  Congenital  absence  of  gland — The  child  is  born  an  idiot 
with  characteristic  appearance  of  thick  lips;  protruding  tongue,  dull 
expression  and  coarse,  dry  skin.  The  patient  improves  and  becomes 
almost  normal  on  being  treated  with  the  gland,  continually  slipping  back 
into  idiocy  with  cessation  of  the  treatment. 

Hyperthyroidism — "Grave's  Disease'' — comes  from  over-activity  of 
the  gland,  and  is  much  like  the  caffeine  psychosis  in  its  symptoms. 
Patients  are  generally  "worriers";  worry  over  everything,  are  ap- 
prehensive, easily  excited,  sleepless,  easily  exhausted.  Show  rapid 
heart  and  breathlessness.  It  is  both  toxic  and  exhaustive  in  nature, 
the  patient's  muscles  have  less  actual  power  because  of  the  toxine. 

Hypothyroidism — from  underactivity  of  the  g"land  (also  called  Myx- 
oedema) .  Patients  on  the  contrary  to  the  above  become  lethargic,  dull, 
stupid,  forgetful,  inactive.  They  tend  to  become  fat  and  pale  and 
doughy  looking ;  they  always  feel  cold  and  sleepy. 

(c)  Exhaustive — from  Extreme  Loss  of  Sleep.  InalDility  to  grasp 
what  is  told,  or  remember ;  loss  of  ambition  ;  irritability.  There  may  be 
delirium. 

Exhaustion  plus  pain,  especially  in  the  old,  often  leads  to  delirium. 

A  man  of  72,  a  bookkeeper,  always  a  hard  worker,  met  with  a  fracture  of  the 
clavicle.  This  necessitated  wearing  a  large  plaster  cast  which  was  very  uncom- 
fortable, especially  as  it  was  hot  svunmer  time.  The  heat,  the  discomfort,  the 
loss  of  sleep,  the  pain  from  the  fracture  were  the  factors.  He  began  to  become 
confused  and  forgot  where  he  was.  then  would  be  taking  part  in  imaginary 
scenes,  that  is,  became  delirious.  He  was  brought  to  the  hospital  and  the 
procuring  of  rest  and  easing  of  pain  finally  resulted  in  recover3^ 
DEMENTIA  FROM   LACK  OF  SLEEP   MAY  OCCUR. 

There  seems  to  be  a  suspension  of  judgment  and  self  criticismi  and 
regard  for  consequences,  the  patient  may  be  easily  suggestible  and 
commit  wild  acts  and  even  crimes, 

DISORDERS  SHOWING  FEATURES  OF  BOTH  A.  AND  B. 

(l)       THE   PSYCHOSES   OF   PREGNANCY 

Are  not  a  separate  entity  and  are  treated  of  in  various  parts  of  this 
syllabus,  but  in  response  to  request,  they  have  been  here  gathered  into 
one  group.    They  are  of  three  kinds : 


MENTAL  DISORDERS  IJ 

(a)  Toxic,  or  more  properly  Toxic-Infective-Exhaustive. 

(b)  Psychogenic — entirely  of  psychic  origin. 

(c)  Combined  Type — showing  symptoms  of  both  the  above  two 

types. 

(a)  Toxic-infecti<vc-exhaustive  may  be  of  renal  or  eclamptic  origin, 
■or  due  to  infection  complicating  the  pregnancy.    The  psychoses  may  be : 

Coma 

Delirium  with  excitement 

Convulsions  may  accompany  either  of  the  above  and  are  a  serious 

sign. 

(b)  Psychogenic — Due  to  the  fact  of  the  pregnancy.  These  may 
be  of  the  type  of  symptoms  described  under 

Hysteria 

Anxiety  Status 

Depression 

Manic-Depressive  Psychosis 

Depression  with  Suicidal  Tendencies.  This  is  a  disorder  the  seri- 
ousness of  which  is  sometimes  not  realized  until  too  late,  when  a 
tragedy  has  occurred. 

(c)  Combined — Any  combination  of  symptoms  may  and  often  does 
occur.  Viz.,  the  toxic  conditions  may  have  hysterical  symptoms  super- 
imposed, etc.  Also,  any  imental  disorder  may  be  complicated  by  a 
pregnancy. 

TREATMENT. 

It  should  now  be  realized  that  a  mental  disorder  which  means  death  or 
insanity  for  the  patient  is  as  urgent  an  indication  for  the  termination  of 
pregnancy  as  advanced  pulmonary  tuberculosis,  or  eclampsia.  A  toxic 
psychosis  merits  no  other  consideration,  unless  very  mild  and  of  an 
indubitably  transitory  nature.     A  psychogenic  disorder  likewise. 

A  Reactionary  Suicidal  Depression  may  be  more  rapidly  fatal  than 
either  of  the  above  two  previously  recognized  physical  indications  for 
termination  of  pregnancy. 

Practice  will  vary  among  physicians  according  to  their  beliefs,  and 
the  fact  that  the  woman  happens  to  be  unmarried  will  cause  some 
physicians  to  say  "Hands  off."  though  the  patient  end  her  life  in  the 
next  hour.  \Miether  the  pregnancy  is  legitimate  or  illegitimate  makes 
no  difference.  It  is  time  that  we  separated  our  double  standard  of 
morality  from  our  ideas  of  medicine.  The  purpose  of  medicine  is  to 
save  life.  No  man  would  impose  on  another  man  the  death  penalty 
merely  for  illicit  sexual  intercourse.  Nor  should  physicians  for  similar 
reasons  impose  upon  women  what  they  would  not  impose  u^x-^n  other 
men  nor  upon  members  of  their  own  immediate  families. 

Accordingly,  as  soon  as  the  diagnosis  is  definitely  established,  it  is 
my  opinion  that  pregnancy  should  be  immediately  terminated,  either  by 


1 8  MENTAL  DISORDERS 

curettage  or  induced  delivery,  since  delay  gains  nothing  and  may  mean 
death  or  a  permanent  psychosis  which  might  otherwise  have  been 
avoided. 

POST    PARTUM    PSYCHOSES. 

After  delivery  certain  psychoses  may  develop.  It  may  be  difficult 
to  state  whether  they  have  been  the  result  of  the  pregnancy  or  were 
impending  at  the  time.  In  some  cases  the  psychosis  may  be  referred  to 
the  infectious  group — the  infection  being  a  more  or  less  mild  "puer- 
peral fever."  Certain  psychoses  seem  to  have  been  impending  and 
occurred  without  regard  to  events  just  preceding  their  appearance,  as 
for  instance  a  Dementia  Precox  which  often  develops  without  as  well  as 
with  so  great  a  physical  and  serological  change  as  pregnancy.  On  the 
other  hand  a  pregnancy  may  precipitate  a  psychosis,  either  toxic  or 
psychogenic,  that  might  otherwise  never  have  occurred. 

(2)       EPILEPSY CONVULSIVE    ATTACKS. 

The  causes  of  epileptic  attacks  are  not  clearly  established  in  all  cases. 
In  some  cases  as  above  they  are  the  definite  results  of  brain  disease 
such  as  a  tumor.  In  what  is  commonly  called  Epilepsy  ("Idiopathic 
Epilepsy")  there  seems  to  be  no  organic  basis  yet  discovered  which 
could  account  for  the  convulsive  attacks.  These  two  types  are  marked 
by  loss  of  consciousness  during  the  attack.  The  patient  is  apt  to  bite 
his  tongue  and  to  wet  or  soil  himself.  The  attack  may  come  on  at  any 
time,  in  any  place.  Others  seem  to  be  of  the  same  type  attack  but  com- 
ing only  in  response  to  a  certain  highly  charged  emotional  setting. 

In  some  other  cases  the  attacks  seem  to  have  developed  entirely  as  a 
symptom  of  Hysteria  (Hitschman — "Freud's  Theories  of  the  Neu- 
roses") so  that  some  cases  should  certainly  be  classified  under  that 
heading.  The  hysterical  epileptic  attacks  often  are  not  accompanied 
by  loss  of  consciousness,  the  patient  as  a  rule  remembers  what  goes 
on  around  him  or  her.  Whether  most  cases  of  epilepsy  are  approach- 
able and  remediable  under  that  conception  has  yet  to  be  discovered. 

We  do  know,  however,  that  most  cases  of  the  spontaneous  epilepsy 
do  show  a  certain  Epileptic  Constitutiou  or  Epileptic  Disposition.  They 
are  as  a  rule  restless,  often  habitually  irritable,  said  by  some  to  be  con- 
stantly trying  to  put  forward  their  own  views  and  draw  attention  to 
themselves.  This  restlessness  at  times  leads  to  extreme  industry,  and 
epileptics  have  had,  and  do  hold,  extremely  important  positions.  Napo- 
leon, for  instance,  was  an  epileptic,  and  once  while  he  was  asleep  during 
an  important  battle  it  was  said  to  be  because  he  was  having  an  epileptic 
attack. 

Their  piety  or  religious  fervor  has  been  marked  by  others,  and  this 
tendency  towards  religion  seems  to  be  more  than  a  surface  ritual, 
but  rather  a  part  of  their  constitution.  It  is  well  known  that  just 
before  or  after  the  convulsion,  many  epileptics   feel  as  if  they  were 


MENTAL  DISORDERS  1 9 

related  to  God  and  had  the  same  omnipotent  power.  I  felt  as  if  any- 
thing I  willed  would  have  to  take  place,"  said  one  epileptic  boy  of  his 
feelings  before  an  attack.  A  very  good  picture  of  this  ecstasy  is  given 
in  Dostoieffsky's  "The  Idiot,"  which  is  the  Russian  term  for  epileptic. 
The  Christlike  character  of  the  hero,  Prince  Muishkin,  is  a  good  study 
of  the  altruistic  epileptic. 

In  connection  with  the  omnipotent  feeling  of  power,  it  is  interesting 
to  note  that  three  great  world  conquerors :  Alexander  the  Great,  who 
sighed  for  more  worlds  to  conquer,  Julius  Caesar,  who  conquered  the 
Gauls,  and  X^apoleon  were  epileptics.  It  shows  what  a  man  of  great 
intelligence  with  possibility  for  power  may  do  if  possessed  of  this 
epileptic  "I  am  invincible"  type  of  mind. 

The  sudden  discharge  of  energy  characteristic  of  Epilepsy  may 
take  place  in  forms  other  than  the  usual  convulsions.  These  have 
been  termed  "Epileptic  Equivalents."  Thus,  in  place  of  a  convulsive 
attack  of  unconsciousness,  a  sudden  attack  of  violence  may  take  place, 
with  forgetfulness  of  the  whole  occurrence  afterward.  Or  the  patient 
may  steal.  Or  he  may  suddenly  and  unaccountably  drop  everything 
and  wander  away  from  homse,  leaving  family,  friends  and  position, 
without  a  w^ord  to  anyone.  There  just. seems  to  come  to  him  an  over- 
powering impulse  to  imove  on.  These  sudden  wanderings  are  called 
by  the  French  "Fugues." 

Sometimes  sudden,  periodic  impulsive  attacks  of  drinking  are  really 
epileptic  equivalents.  The  patient  may  go  for  weeks  or  months  without 
a  drink,  then  suddenly  he  begins  and  takes  one  drink  right  after 
another  until  intoxicated.  He  may  be  found  by  his  friends  in  low- 
resorts,  or  come  to  consciousness  himself.  After  the  attack  he  may  be 
depressed  and  self-accusatory  and  quite  industrious  and  efficient  until 
the  next  attack. 


B     MENTAL  DISORDERS  EXPLICABLE  IN  PSYCHOLOGI- 
CAL TERMS— THE  EMOTIONAL  DISTURBANCES 

e;motion  guidks  behavior. 

If  the  preceding  half  of  the  book  has  dealt  almost  exclusively  with 
conditions  that  belong-  to  the  realm  of  general  medicine,  this  section 
that  follows  is  just  as  completely  a  matter  of  human  nature  and  ever}- 
day  experience. 

The  psychogenic  disorders  are  disturbances  of  the  emotional  nature. 
They  are  a  matter  of  personality,  interest,  tastes,  development  and 
personal  experience  rather  than  a  question  of  accidental  injury  or 
disease.  Their  nature  is  personal  and  the  active  processes  are  per- 
sonal, not  external.  We  here  deal  more  with  the  individual  life  and 
less  with  an  attempt  to  vary  impersonal  conditions. 

When  at  any  time  we  come  to  study  the  behavior  of  an  individual, 
we  find  that  action  is  very  largely  the  result  of  mood,  or  emotional 
color  or  afifect — not  a  matter  of  pure,  cold  reason.  To  use  a  crude 
example,  we  patronize  a  certain  store  because  we  have  a  warm  glow 
of  cheery  associations  with  that  store ;  we  avoid  certain  streets  be- 
cause they  are  unpleasant  to  us.  It  is  easier  to  buy  a  thing  we  zvant 
than  a  thing  we  need.  The  successful  salesman  is  very  cognizant  of 
this  and  immediately  seeks  to  establish  pleasant  relations  with  his  pro- 
spective customers — to  interest  them,  to  tickle  their  vanity,  etc.  So 
that  ^'Arousing  Favorable  Interest*'  is  the  first  step  in  salesmanship 
as  taught  in  the  text-books  and  "salesmanship  courses." 

It  is  almost  impossible  to  overestimate  the  role  of  emotion  in  our 
everyday  life  and  action.  Many  of  the  most  important  steps  in  a 
man's  or  woman's  life,  viz.,  the  choosing  of  a  career,  are  made  on  a 
basis  in  which  emotion  has  a  very  large,  if  not  the  preponderating,  part. 

Let  us  consider  the  naive  description  given  by  Philip  Jourdon  of  the 

manner  in  which  he  fell  in  love  with  Cecil  Rhodes — which  led  to  his 

becoming  the  latter's  secretary  and  thus  determined  the  course  of  his 

life  for  years  afterwards. 

"It  was  about  a  year  after  I  first  met  him  that  an  almost  uncoiitrollaI)le 
desire  took  hold  of  me  to  be  his  private  secretary  and  to  travel  over  the  world 
with  him.  In  my  mind  I  had  placed  him  on  such  a  high  pinnacle  of  fame  that 
such  a  wish  seemed  almost  impossible  of  realization.  Sometimes  I  felt  I  dared 
not  even  think  of  it.  It  was  my  great  secret  and  I  did  not  communicate  it  to  a 
soul.  I  delighted  to  harbor  the  idea,  and  sometimes  I  would  lie  awake  half  the 
night  working  myself  up  into  a  state  of  delirious  excitement  speculating  on  the 
joy  and  pleasure  which  would  be  mine  when  I  should  be  his  secretary,  when  I 
should  be  always  with  him  and  would  go  wherever  he  went.  1  had  not  then 
received  the  slightest  hint  from  him  that  there  was  even  a  possibilitj'  o-f  my 
appointment  as  his  secretary.  1  worshipped  him  and  had  an  intense  desire 
to  work  for  him  and  to  please  him." 

20 


MENTAL  DISORDERS  21 

For  Other  examples,  one  need  but  consider  the  accounts  of  history 
and  hterature  to  see  the  power  that  that  very  subtle  and  complex 
emotion  which  we  call  love  has  to  influence  the  lives  of  people,  and 
through  them  even  the  destinies  of  empires. 

And  emotion  is,  in  turn,  essentially  of  the  subconscious.'''  Alade  up  of 
inherited  qualities,  from  pleasant  or  painful  associations  gathered  daily 
and  hourly  from  the  moment  of  birth  onward  they  come  suddenly  out 
of  the  dark  domain  of  our  mind  to  flood  our  consciousness  and  sweep 
us  over  the  barrier  of  cjuiescence  into  activity.  We  merely  act  be- 
cause we  want  to — we  dcAi't  know  why.  We  have  been  directed  by  our 
subconscious. 

The  evolution  of  feeling  outward  into  thought  and  action  is  neatly 
described  by  Edward  Carpenter : 

"Feeling  (or  desire)  lies  beneath.  Thought  is  the  form  which  it  takes  as  it 
comes  into  the  outer  world.  Let  us  take  a  definite  instance.  We  desire  to 
travel.  The  desire  begins  first  as  a  mere  vague  sense  of  discomfort  or  rest- 
lessness ;  presently  it  takes  shape  as  a  wish  to  leave  home  or  to  visit  other 
regions.  It  may  remain  at  that  for  some  time ;  then  it  takes  somewhat  more 
definite  shape — as  to  go  to  the  seaside.  Then  we  consult  our  wife,  we  consider 
ways  and  means,  we  fumble  through  Bradshaw,  the  thought  of  Margate  comes 
as  a  kind  of  inspiration,  and  a  quite  distinct  and  clearly  formed  plan  emerges. 

"Or  we  wish  to  build  ourselves  a  house  of  our  own.  For  a  long  time  this 
may  only  be  a  kind  of  cloudy  pious  aspiration.  But  at  last  and  almost  in- 
evitably, the  dream  of  the  house  takes  shape  within  our  minds.  We  get  so  far 
as  to  make  a  pencil  sketch  of  what  we  want.  We  go  and  prospect  a  site.  We 
consult  an  architect,  and  presently  there  emerges  a  much  more  definite  and 
detailed  plan  than  before.  Then  steps  are  actually  taken  towards  building. 
Heaps  of  bricks  and  stone  and  other  material  begin  to  appear  on  the  scene ;  and 
at  last  there  is  the  house  standing,  which  once  only  existed  in  the  dream-world 
of  our  minds.  Always  the  movement  is  outward,  from  the  indefinite  vague 
Feeling  or  desire  to  the  definite  clearly  formed  Thought,  and  thence  to  Action 
and  the  External  World." 

So  that  we  may  say  that  action  or  behavior  is  largely  a  function  of  the 
subconscious,  its  motive  power  being  emotion.  Probably  most  of  our 
behavior  is  a  result  of  this  almost  automatic  functioning. 

The  terms  "normal"  and  ''abnormal"  are  arbitrary  and  indicate  de- 
gree of  reaction — not  kind  of  reaction.  Because  only  when  this  auto- 
matic behavior — our  likes  and  dislikes,  our  loves  and  hates,  our  bold- 
nesses and  fears — are  in  general  much  like  those  of  most  of  the  people 
around  us,  our  social  group,  do  we  call  it  normal  and  accept  it  as  such. 
But  codes  of  behavior  vary  greatly  among  different  races.  Oriental 
and  Occidental,  savage  and  civilized,  tropical  and  of  temperate  zone, 

*  (Whereas  we  will  here  employ  the  old  distinction  of  conscious  mind  and 
subconscious  or  unconscious-mind  as  if  there  were  a  sharp  line  dividing  them, 
nevertheless  we  must  realize  that  what  is  subconscious  or  unconscious  is  con- 
tinually becoming  conscious  in  the  form  of  memories,  phantasies,  imaginations, 
and  the  like;  and  what  is  conscious  is  continually  dropping  into  the  unconscious 
or  subconscious,  is  being  forgotten,  and  either  takes  place  instantaneously.  Con- 
scious, semi-conscious,  and  subconscious  are  artificial  divisions  laid  out  on  ©ne 
continuous  piece  of  material.) 


22  MENTAL  DISORDERS 

and  just  as  much  among  the  different  social  strata  of  the  same  race. 
A  gamin  of  the  streets  is  brought  up  on  a  very  different  code  than  a 
judge-advocate,  a  workman  than  a  financial  man.  Herein  perhaps  Hes 
much  of  the  dissension  in  Hfe. 

Now,  "unusual  behavior"  or  "abnormal  behavior"  is  merely  that 
which  is  different  from  our  usually  accepted  code,  and  varies  widely 
acccording  to  the  code  we  adopt  as  standard.  The  terms  are  relative 
only.  Yery  often  behavior  or  action  which  may  at  first  look  very 
queer,  turns  out  to  be  very  commonplace  when  we  discover  the  person's 
avowed  purpose  for  so  doing.     For  instance : 

A  young  woman  strolling  one  Sunday  morning  in  the  square  about  the 
Washington  Monument  was  suddenly  struck  by  seeing  a  man  half  bowing,  half 
in  a  genuflection  before  one  of  the  statues  that  adorn  that  vicinity.  Imme- 
diately she  felt  herself  in  the  presence  of  a  lunatic,  and  in  some  perhaps  un- 
guessed  danger.  In  surprise  and  fear  she  clutched  her  companion  and  screamed, 
"Look,  Look !"  pointing.  The  man  then  gravely  turned  around  and  the  girl 
finally  saw  that  he  had  a  kodak  in  his  hands  and  had  been  merely  trying  to  get 
a  good  focus  on  the  statue.  The  girl  was  so  relieved  that  she  collapsed  on  some 
nearby  steps,  overcome  with  laughter. 

Perhaps  all  behavior  would  in  the  same  way  be  comprehensible  to 
us  if  we  could  see  "clues  to  the  workings  of  the  individual's  mind 
behind  it,  i.  e.,  if  we  could  trace  back  of  the  action  a  familiar  motive; 
that  is,  one  which  we  feel  in  ourselves. 

In  fact  all  abnormal  behavior  when  subjected  to  analysis  shows  us 
practically  the  same  underlying  forces  at  work  as  normal  behavior, 
being  only  extreme  behavior,  not  abnormal. 

But  the  point  is  that  we  often  do  not  see  these  motives  behind  the 
patient's  actions,  generally  the  patient  does  not  himself.  His  behavior 
taken  broadly  is  merely  reaction  to  stimulus  and  the  reason  that  the 
patient  can  not  control  his  abnormal  behavior  is  because  he  does  not 
control  his  normal  behavior.  It  is  our  task,  then,  to  increase  our  insight 
into  the  patient's  mind. 

Therefore,  in  studying  the  psychogenic  disorders,  we  wish  to  dif- 
ferentiate the  various  forms  of  thought  disorders  or  unusual  thought 
life  as  shown  by  their  outward  manifestation,  namely  speech  and  be- 
havior. Then,  bearing  in  mind  that  we  are  going  to  find  the  same 
factors  at  work  which  activate  ourselves,  we  try  to  discover  as  far  as 
possible  the  emotional  state  lying  beneath  these  symptoms.  Finally  we 
wish  to  arrive  at  the  causes  of  this  emotional  state. 

I.    THE   ELATION-DEPRESSION    OSCILLATION' 

Or  Manic-Depressive  Psychosis. 

This  seems  to  be  an  exaggerated  form  of  reactions  which  are  com- 
monly found  in  normal  life.  All  of  us  have  felt  elated  at  various  times, 
but  in  the  course  of  a  little  while — hours  or  minutes,  perhaps — the 
extreme  elation  has  diminished,  and  in  a  few  davs  or  less  all  effects 


MKXTAL   DISORDERS  23 

have  disappeared.  If  this  elation  keeps  up  in  the  heightened  state  for 
days,  or  if  it  continues  to  increase  and  increase  in  intensity  it  becomes 
a  chronic  elation  or  manic  condition. 

Likewise,  depression  which  comes  to  everyone  some  time  or  other 
in  varying'  degree  and  duration,  if  it  tends  to  endure  becomes  an 
abnormal  state.  And  either  elation  or  depression  once  established, 
it  is  well  known  medically,  might  change  very  quickly  into  the  other. 

a.     The  Characteristics  of  approaching  Elation,  or  Hypomanic 

State. 

The  onset  may  take  days  or  weeks,  the  patient's  mood  gradually  be- 
coming more  and  more  excited.  The  patient  begins  to  feel  more  keen, 
more  wide-awake,  more  active  and  efficient  than  ever  before.  He 
feels  a  notable  increase  in  his  ability  to  calculate  and  to  plan  and  to 
handle  a  multitude  of  details  (lifting  of  inhibitions).  His  mind  seems 
clearer  and  he  can  jump  more  readily  from  idea  to  idea,  from  plan  to 
plan.  He  needs  less  sleep  than^^efore.  Added  to  this  he  is  elated; 
he  "feels  fine,"  he  "just  touches  the  high  spots,"  "business  never  went 
so  well  before,"  "this  is  a  fine  old  world,"  etc.,  (hypomania). 

So  far  everything  is  to  the  good  one  might  say  and  perhaps  all  of  Us 
should  normally  feel  a  little  more  keen,  a  little  more  active,  a  little 
better  able  to  handle  our  work.  Perhaps  also  we  would,  if  we  were 
doing  only  such  work  as  we  were  intensely  interested  in  and  fitted  for. 
If  the  disorder  stopped  here  all  would  be  well  and  it  has  sometimes 
happened  that  a  large  business  has  been  developed  by  a  man  in  this 
hypersanguine  state. 

But  to  his  friends  and  associates  the  manic  patient  begins  to  seem  a 
little  too  optimistic ;  he  may  seem  to  overestimate  his  strength,  his 
gayety  may  seem  a  little  more  enduring  than  every  occasion  calls  for, 
his  laugh  may  seem  a  trifle  too  frequent  and  too  hearty.  And  this 
soon  continues  beyond  all  bounds  of  doubt.  Fantastic  schemes  are 
entered  into,  gigantic  financial  projects  are  launched  certain  of  failure; 
the  patient  works  feverishly  day  and  night  trying  to  bolster  up  the 
colossal  but  insecure  structures  he  has  thrown  up. 

But  it  is  no  go  and  if  he  is  not  quickly  taken  care  of  the  world  comes 
tumbling  about  his  ears.  The  various  impossible  projects  fail,  credi- 
tors appear,  wild  escapades  bring'  demands  for  retribution.  This 
state  may  be  almost  as  disastrous  for  the  time  being  as  General 
Paresis,  but  there  are  many  redeeming  features,  the  patient  usually 
remembers  and  can  give  an  account  of  what  he  has  done ;  and  recov- 
ery usually  takes  place. 

But  what  is  the  patient's  behavior  as  the  elation  increases  ? 

CHARACTERISTICS   OF    MAXIC   STATE. 

He  is  very  active  moving  alx)ut  his  room  rapidly  or  talking  away — 
there  seems  to  be  great  press  of  activity.  It  seems  as  if  something 
inside  keeps  him  on  the  go.     In  his  speech  he  shows  a  rapidity  both 


24  MENTAL  DISORDERS 

of  words  and  ideas,  he  jumps  quickly  from  subject  to  subject,  and 
from  word  to  word,  apparently  with  but  the  most  superficial  association 
from  one  to  another.  He  can  be  easily  distracted  and  his  line  of  talk 
shifted  by  any  slight  movement  or  noise  about  him.  Viz. :  if,  during  his 
stream  of  talk  keys  are  rattled,  somewhat  this  result  will  happen : 
"Millions — trillions — quadrillions — (keys  jingled)  keys — I've  got  'em — 
you've  got  'em — keys  to  Heaven — God — Heavenly  Father — angels — 
golden  hair — gold — money,"  etc. 

He  is  extremely  elated,  self  criticism  has  long  ago  been  forgotten. 
he  laughs  and  makes  noises  and  smiles  at  all  about  him. 

At  times  a  patient  presents  an  irritable  or  ill-tempered  mania — 
hyperactivity,  rapidity  of  speech  with  corresponding  shallowness  of 
thought  combined  with  irritation  and  combativeness.  This  is  rather 
rare. 

Finally,  much  purposeless  action,  piore  like  playing,  is  the  result. 
He  saves  and  files  away  pieces  of  paper,  pages  from  magazines,  etc. ; 
decorates  his  room  with  all  manner  of  bright  objects,  materials,  and 
wearing  apparel.  He,  apparently  in  fun,  miscalls  names,  gives  all 
around  him  fictitious  names  and  titles,  and  goes  through  imaginary 
scenes  with  them  in  which  he  himself  plays  the  leading  part.  He  is 
an  explorer,  a  conqueror,  or  a  king. 

The  whole  picture  strikes  one  at  times  as  play  acting,  and  the 
superficiality  of  thought  association  bears  this  out.  The  situation  seems 
to  be  a  way  of  escape  from  some  mental  conflict  which  may  or  may 
not  be  discovered  on  investigation.  It  is  like  laughing  to  cover  em- 
barrassment. 

This  reaction  tends  to  recovery  from  the  attack  in  most  cases, 
which  may  take  place  in  a  few  days  or  not  until  after  months.  There 
is  very  often  a  tendency  to  recurrence,  and  a  fourth  or  fifth  attack 
is  apt  to  be  much  slower  at  clearing  up  than  the  first  or  second.  Elation 
may  alternate  with  depression. 

(b)     Depressi-on. 

Here  we  have  just  the  opposite  picture  to  the  above.  Instead  of 
feeling  happy,  the  patient  feels  always  ''blue"  or  depressed.  He  is 
quite  inactive  and  does  things  only  with  greatest  difficulty.  Speech, 
thought,  and  action  are  all  slow.  All  his  inhibitions  seem  increased  to 
an  almost  overwhelming  degree.  A  decision  seems  sometimes  impos- 
sible for  him  to  make.  He  will  decide  to  go  out  and  take  a  walk,  get  to 
the  door,  and  want  to  go  back;  then  wish  he  were  out  on  the  street. 
After  much  mental  agony  he  may  get  out,  then  it  is  difficult  to  decide 
what  street  to  follow,  or  whether  he  should  take  a  street  car,  and 
which  one ;  or  whether  he  hadn't  better  return  at  once ;  but  he  should 
get  exercise,  etc.,  etc. 


*MEXTAL  DISORDERS  2y 

In  addition  he  may  be  very  self  critical  and  have  ideas  of  his  own 
unworthiness  and  accuse  himself  of  being  a  failure,  unworthy,  poverty- 
stricken,  a  thief.  He  may  think  that  through  him  the  whole  family 
is  reduced  to  poverty. 

Just  as  elation  or  depression  may  readily  change  one  into  the  other, 
so  also  we  sometimes  find  the  symptoms  of  the  two  types  intermingled. 

The  inaccessibility  of  the  patient  in  either  the  manic  or  the  depressed 
phase  would  suggest  that  the.  psychosis  is  a  trick  of  the  subconscious 
to  avoid  some  painful  combination  of  thoughts ;  and  in  this  regard  it 
would  seem  to  be  a  "protective  insanity,"  rather  than  an  "overwhelming 
insanity." 

A  college  professor  who  had  all  his  life  had  periods  of  months  in  which  he 
felt  particularly  active  and  efficient — work  went  particularly  well — alternating, 
with  periods  of  months  in  which  work,  especially  new  creative  work,  seemed 
almost  impossible.  (Alild  elated  or  depressed  attacks,  i.  e.,  manic-depressive 
constitution).  At  the  age  of  59  he  felt  constantly  increasing  difficulty  in  his 
work  until  it  linally  seemed  impossible.  His  attempts  to  resist  this  finally  ended 
in  a  fainting  attack  during  some  exercises  in  which  he  was  taking  part,  and 
from  which  he  had  to  be  carried. 

Following  this  his  depression  was  so  well  established  that  it  necessitated  his 
removal  to  the  hospital.  On  entrance  he  was  quite  despondent.  He  answered 
only  very  slowly  and  after  considerable  pause.  He  tended  to  blame  himself 
very  severely  for  matters  which  he  had  thought  quite  satisfactory  at  the  time, 
but  in  which  he  now  saw  cause  for  self-reproach,  namely  matters  of  admin- 
istration, and  some  sexual  conflicts.  Memory  was  unimpaired,  but  the  process 
of  recalling  events  was  delayed  somewhat  b\-  the  slowness  of  association  proc- 
esses. Calculation  was  likewise  delayed.  Orientation  was  clear.  The  man 
had  clear  insight. 

After  some  months  of  this  depression  the  mood  began  to  change,  the  great 
inhibition  began  to  lift,  his  normal  processes  became  more  facile,  and  he  began 
to  assume  a  normal  appearance.  This,  however,  lasted  only  a  few  days.  Inhibi- 
tions w^ere  removed  more  and  more.  The  previously  deeply  melancholy  pro- 
fessor became  jolly,  then  elated.  He  became  talkative,  entertained  his  fellow 
patients  with  risque  stories  such  as  he  had  never  employed  before.  This  elation 
gradually  increased  until  the  manic  phase  was  reached.  The  patient  rose  at 
four  in  the  morning,  danced  all  day,  w^rote  innumerable  epistles  and  haphazard 
articles  consisting  of  paragraphs  of  merely  a  sentence  or  two,  or  just  a  few 
words.  He  wrote  a  poem  to  his  wdfe  w^hich  had  a  rather  presentable  lyrical 
quality. 

After  several  months  of  this  he  became  more  and  more  quiet  until  a  period 
of  normal  mood  and  thought  action  were  reached,  in  which  condition  he  left  the 
hospital. 

Mild  grades  of  this  manic-depressive  reaction  are  called  Cyclothymia. 
In  this  the  patient  shows  elation  or  depression  which  is  beyond  the 
bounds  of  normal  behavior  but  never  reaches  the  extremes  described 
above.  Sometimes,  however,  these  abnormalities  of  mood  and  judg- 
ment are  overlooked  at  the  time. 

2.    DEPRESSIONS  APPARENTLY  NOT  OE  THE  MANIC-DEPRESSIVE  GROUP. 

(a)  Those  incidental  to  certain  diseases,  such  as  some  heart  condi- 
tions, fatigue;  convalescence  from  certain  diseases — Influenza,  Ton- 
silitis,  etc.  These  should  be  perhaps  listed  under  the  toxic-exhaustive 
group,  but  there  is  probably  a  combination  of  both  physical  and  psy- 


26  MENTAL  DISORDERS 

chogenic  causes,  i.  e.,  the  depression  may  be  partly  due  to  the  weak^ 
ness,  but  no  less  due  also  to  the  confinement,  or  to  the  inability  to  act 
or  think  which  is  experienced. 

(b)  Depression  with  hallucinations,  i.  e.,  "seeing  things"  (visual), 
or  ''hearing  things,"  usually  voices,  (auditory).  The  manic-depres- 
sive depression  is  free  from  hallucinations,  and  their  presence  generally 
indicates  much  more  serious  prognosis. 

(c)  Depression  with  paranoid  trends,  i.  e..  Delusions  of  Persecu- 
tion. In  some  cases  these  seem  incidental  to  the  depression  and  dis- 
appear as  the  depression  disappears.  Prognosis  here  much  better  than 
in  Paranoia  without  depression. 

A  man  of  52  entered  the  clinic,  being  markedly  depressed  and  self-accusator}-. 
He  upbraided  himself  for  having  committed  several  sharp  practices  in  business, 
and  stated  that  his  wife  was  getting  a  divorce  from  him.  He  had  always;  been 
of  the  manic-depressive  constitution,  either  very  jolly,  or  so  depressed  that 
he  would  not  speak  to  his  family  for  a  week.  There  had  been  several  emotional 
factors  in  his  personal  life,  fear  of  having  children,  which  neither  he  nor  his 
wife  desired,  fear  of  infecting  his  wife  (he  had  acquired  lues  some  years  pre 
vious),  and  recently  a  loss  of  potentia. 

His  depression  continued  and  got  worse,  and  he  became  more  self-accusatory. 
Soon  he  began  to  develop  paranoid  ideas  :  Because  of  his  business  dealings,  he 
was  going  to  be  sent  to  the  penitentiary.  Everyone  in  the  hospital  was  in  a  con- 
spiracy against  him  to  arrange  this.  Whenever  the  doctor  patted  him  on  the 
shoulder,  it  had  some  hidden  meaning,  though  just  what  this  was  he  didn't 
know. 

After  some  weeks  the  depression  began  to  lighten  and  he  became  less  despondent 
and  less  self-accusatory.  At  the  same  time  the  ideas  of  the  conspiracy  againsc 
him,  the  deep  significance  for  himself  which  he  attached  to  the  actions  of 
everyone  else,  disappeared.  The  paranoid  ideas  had  merely  been  a  phase  of,  or 
had  been  incidental  to,  the  depression. 

In  some  cases,  however,  the  delusions  seem  more  permanently  es- 
tablished. It  is  often  difficult  to  differentiate  these  two  types  in  order 
to  give  prognosis  until  after  long  observation  of  the  patient. 

(d)  Agitated  Depression — more  properly  often  the  end  stage  of  an 
Anxiety  Neurosis  (see  below).  The  patient  is  constantly  weeping 
and  is  apprehensive  and  is  depressed.  He  or  she  accuses  himself  and 
worries  and  is  inconsolable.  This  forms  a  vicious  circle:  The  worry 
and  self-accusation  and  sleeplessness  cause  the  patient  to  be  in  turn 
more  worried,  agitated  and  restless. 

3.       ATYPICAL  EXCITEMENTS. 

Excitements  which  are  not  typical  of  the  manic  excitement  nor  yet 
showing  deterioration. 

A  young  man  of  28  who  came  of  unassuming  laboring  stock,  had  by  dint  of 
much  effort  and  thinking,  raised  himself  above  his  surroundings  to  the  extent 
of  becoming  a  broker's  clerk.  From  there  he  changed  to  other  offices,  always 
doing  a  good  deal  of  calculating  and  dabbling  in  business  deals.  After  several 
months  of  over-time  work,  which  kept  him  at  the  office  until  all  hours  at  night, 
he  became  excited. 

On  entrance  to  the  hospital  he  was  rather  elated  and  smiled  pleasantly  as  if 
happy.     He  kept  repeating,  "I  played  the  game  to  win.     I  played  the  game  to 


MENTAL  DISORDERS  '  2/ 

win."  But  though  he  was  elated,  there  was  only  slight  flight  of  ideas,  and  there 
seemed  to  be  no  press  of  activity.  When  addressed  he  would  answer  briefly 
and  smile,  but  would  talk  very  little. 

As  the  excitement  abated,  he  became  quiet  and  had  more  difticulty  in  answer- 
ing, waiting  an  appreciable  space  of  several  seconds  before  replying.  He  took 
little  interest  in  amusements  and  light  occupational  work,  and  would  sit  for 
hours  in  a  lethargic  state,  semi-smiling,  and  following  the  nurse  or  attendant 
about  with  his  ej^es.    This  retarded  condition  persisted  for  some  weeks. 

We  hence  have  in  this  case  symptoms  of  the  Manic-Depressive  and  also  of 
the  Schizophrenic  reaction  types,  but  not  conclusive  for  either. 

4.      PARANOIA    OR    DELUSIONAL    STATE. 

Delusions  li'Jiich  may  be  Perscciiiory,  Grandiose,  or  Erotic.^    No 
•^  Deterioration  present. 

The  term  paranoia  is  usually  reserved  for  delusions  of  persecution, 
but  it  really  covers  all  the  delusional  states  including  the  delusions  of 
grandeur  and  erotic  delusions.  A  patient  who  has  one  delusion  is 
apt  to  have  several,  thus  a  patient  who  thinks  everyone  is  against  him 
(persecutory)  may  be  said  to  be  grandiose  in  his  self-importance.  A 
man  with  megalomanic  or  grandiose  ideas,  i.  e.,  who  thinks  he  is  tre- 
mendously wise  or  rich  or  powerful  in  the  face  of  obvious  evidence  to 
the  contrary,  may  soon,  because  other  people  take  the  contrary  view, 
believe  that  everyone  is  in  league  against  him.  A  man  may  think  that 
some  very  prominent  woman  whom  he  has  never  met  is  in  love  with 
him,  that  he  has  a  great  attractiveness  and  a  great  power  which  she 
r^els.    Then  an  erotic  and  a  grandiose  delusion  occur  together. 

^  Xrhe  classic  picture  is  of  a  patient  who  thinks  people  are  against 
him,  or  are  even  making  attempts  on  his  life  through  poisoning  or 
causing  accidents  to  happen  to  him,  or  there  may  be  an  organized  move- 
ment on  foot  to  do  him  harm.  (Persecutory  Type).  Everyone  is 
then  pla^ceH  in  iHe  hostile  combine,  and  every  occurrence  of  his  life, 
every  person  he  meets,  his  words,  actions,  etc.,  all  are  _  given 
special  significance  as  being  concerned  directly  with  him.  ;  This  is 
the  most  difficult  of  all  diseases  to  treat,  as  it  is  impossible  to  get  the 
patient's  confidence  and  cooperation.  For  as  a  rule  he  places  the 
doctor  immediately  among  his  enemies,  and  this  ends  any  further  satis- 
factory interviews.^) 

Persons  who  have  this  form  of  disorder  are  often  dangerous.  It  can 
be  easily  seen  that  if  the  patient  thinks  a  certain  person  is  making 
attempts  against  his  life,  he  will  consider  the  best  plan  is  to  kill  this 
person  at  once  and  so  remove  him  from  his  path.  Under  such  delu- 
sions many  murders  are  committed.  Some  authorities  claim  that 
only  those  paranoiacs  are  dangerous  in  whom  there  is  also  deteriora- 
tion but  it  is  very  difficult  to  draw  the  line  here. 

The  patient,  a  man  of  38,  single,  a  mail-carrier,  had  always  been  seclusive, 
without  friends  or  confidants.  He  was  the  oldest  of  the  family,  there  being  a 
younger  brother  and  two  sisters,  and  the  patient  was  always  domineering  towards 
them,  especially  the  brother,  and  insisting  on  having  his  way.     Of  late  years  ho 


28  me:ntal  disorders 

had  been  very  aggressive  toward  his  brother,  saying  that  he  was  trying  to  master 
him.  Frequently  he  would  say,  "You  do  anything  to  me  and  I  will  get  you 
for  it." 

He    further   thought   that   people   along   his    route   were   planning   something 
against  him,  so  that  he  had  quarreled  with  every  one  of  them.     Moreover,  he 
had  thrown  rocks  against  the  house  of  a  certain  girl  cousin,  and  on  one  occasion 
^ad  exploded  a  stick  of  dynamite  on  her  doorstep. 

It  is  impossible  to  say  definitely  whether  this  disease  rests  upon 
organic  disturbance  or  upon  functional  grounds,  i.  e.,  upon  factors 
which  can  be  discussed  entirely  in  the  light  of  psychology.  The  bal- 
ance of  opinion  seems  of  late  years  to  favor  the  psychological  inter- 
pretation of  the  disease.  Such  patients,  long  before  developing  para- 
noia, show  a  particular  disposition.  They  seem  inordinately  welded 
to  their  own  ideas,  and  will  not  change  them  even  after  experiences 
that  would  prove  themselves  wrong.  There  seems  present  a  very  ex- 
aggerated self-importance  and  self-esteem,  amounting  to  overwhelm- 
ing self-love.  This  makes  himself  the  center  of  all  his  attention  and 
hence,  he  judges,  of  other  people's.  The  step  from  this  self-importance 
to  feeling  that  people  are  persecuting  him  is  easy.  He  regards  him- 
self so  highly  that  he  thinks  others  regard  him  with  equal  importance. 
Everything  that  anyone  says  has  a  personal  reference  to  himself  (ideas 
of  reference).  Soon  he  thinks  that  everyone  must  be  jealous  of  him. 
The  origin  of  this  self-love,  or  narcism,  will  be  taken  up  later.  Suffice 
it  to  say  here  that  it  seems  to  be  an  mfantile  reaction  which  gives  a 
feeling  of  comfort  or  pleasure,  and  is  a  way  of  escape  from  unpleasant 
mental  conflicts. 

True  paranoia  (without  apparent  deterioration)  is  to  be  differentiated 
from  Paranoid  Dementia  Precox  of  which  deterioration  is  an  out- 
standing characteristic. 

5.       DKMENTIA  PRECOX. 

Also  called  Insanity  of  Adolescence,  or  Schizophrenia. 

The  terms  mean  much  the  same.  Dementia  Precox  means  early 
dementia;  namely,  a  mental  disorder  coming  on  in  overwhelming  pro- 
portions about  at  adolescence.  Schizophrenia  means  a  splitting  of 
thought-processes.  This  conception  advances  us  little,  however,  beyond 
what  is  covered  by  the  term  insanity  or  dementia,  though  it  perhaps 
would  suggest  a  disorder  not  of  structural  origin. 

Though  the  disorder  is  probably  a  matter  of  gradual  development, 
the  onset  may  go  unnoticed  until  the  parents  or  friends  are  suddenly 
surprised  by  a  great  and  rapid  change  in  the  patient's  personality.  The 
girl  or  boy  may  find  himself  unable  to  concentrate  his  attention  on  the 
external  world  and  to  do  any  work  that  requires  such  attention.  And 
he  may  be  equally  unable  to  describe  what  is  the  nature  of  his  dis- 
order. In  short,  a  very  sudden  and  extensive  confusion  has  taken 
place.  This  is  the  full  blown  disorder.  Hence  it  seems  advisable  to  us 
to  describe  the  disorder  in  its  earlier  and  less  obvious  stages. 


MI;NTAL     DISORDERS  29 

DEVELOPMENT    STAGE    OR    PRE-DEMENTIA    PRECOX. 

It  seems  fair  to  embody  this  as  part  of  the  account  since  in  most  cases 
the  disorder  has  occurred  in  a  certain  definite  type  of  personaHty — 
called  the  "shut  in,"  really  "driven  in,"  personality.  The  boy  or  girl 
is  introspective,  subjective,  his  interest  is  apparently  turned  in  on  him- 
self, he  has  no  confidant  to  whom  he  can  unbosom  himself — 
perhaps  he  feels  so  deeply  that  the  feeling"  is  inarticulate.  He  prefers 
to  be  alone  rather  than  in  company,  is  seclusive,  shy,  sensitive,  easily 
embarrassed.  This  description  fits  equally  many  youths  of  both  sexes 
who  through  the  vicissitudes  of  development  and  education  come  to 
adolescence  unconscious  of  their  forces,  and  unprepared  for  self 
■direction.  One  of  the  characteristics  of  adolescence  is  inarticulateness. 
Some  further  unknown  factor,  however,  seems  to  be  necessary  to  pre- 
cipitate the  tragedy. 

Another  pre-Dementia  type  seems  to  include  persons  who,  through 
inferior  nxental  capacity,  habitually  bungle  situation  after  situation,  be- 
coming discouraged  and  then  more  bungling  and  finally  develop  the 
final  condition  described  as  Dementia  Precox. 

Any  mental  disturbance,  then,  in  a  young  person  during  the  years  of 
adolescence  should  immediately  be  regarded  with  the  greatest  serious- 
ness. And  a  sudden  change  in  personality  occurring  in  a  hyper-sensi- 
tive and  introspective  girl  or  boy  with  inability  to  do  any  work  (often 
misconstrued  as  intentional  unwillingness)  combined  with  an  inability 
to  explain  his  difficulty,  is  apt  to  be  evidence  of  the  presence  of  this 
psychosis. 

CHARACTERISTICS  OF  DEMENTIA  PRECOX 

These  symptoms  occur  in  a  frequently  changing  variety  of  combi- 
nation, and  no  description  of  the  disorder  is  adequate  unless  it  embodies 
this  idea  of  continual  change  from  one  picture  to  another.  It  must  be, 
as  it  were,  a  motion-picture  in  words.  Four  commonly  occurring 
phases  or  pictures  or  types  have  been  used.  But  all  the  features  of 
one  often  do  not  occur  together  and  sometimes  one  or  more  features 
of  other  types  may  be  present.     The  types  are: 

(a)  Simple  Type 

(b)  Hebephrenic 

(c)  Catatonic 

(d)  Paranoid 

(a)  Simple  Type. 
The  patient  who  may  have  been  a  brilliant  boy  or  girl  gradually 
begins  to  avoid  company  or  the  family,  and  keeps  to  himself.  There 
seems  to  be  a  gradual  but  very  marked  change  in  the  personality.  He 
may  sit  for  hours  absorbed  in  day  dreams,  or  reminiscences,  or  spin- 
ning idle  plans  or  fantasies  which  he  does  not  try  to  carrv  into  action. 


^O  ,  MKNTAL  DISORDERS 

It  seems  much  as  if  the  mental  processes  were  blocked  at  the  point 
where  they  flow  out  into  action,  as  if  but  endless  reflection  were 
allowed. 

He  may  be  irritable  or  evidently  worrying ;  perhaps  he  cannot  sleep 
at  night,  and  he  alarms  the  family  by  arising  and  wandering  about, 
restless  and  unhappy.  There  may  be  sudden  unaccountable  outbursts 
of  weeping,  or  of  excitement,  or  of  temper.  He  may  attach  undue 
importance  to  insignificant  incidents,  thinking  that  every  remark  he 
hears  is  being  made  about  him,  whenever  he  sees  anyone  laugh  that 
person  is  laughing  at  him,  etc.  Further  inquiry  may  elicit  a  history  of 
excessive  indulgence  in  masturbation.  This  taken  with  the  endless 
fancies  which  result  in  no  action  would  seem  to  indicate  a  turning  in  of 
the  interest  on  himself  with  a  resulting  loss  of  interest  in  making  sorties 
into  the  outside  world. 

To  all  questions  he  probably  answers  that  he  does  not  feel  well, 
perhaps  he  cannot  name  his  difficulty.  He  may  go  to  bed  and  spend  all 
his  time  there,  and  people  remark  on  the  strangeness  of  a  person  ap- 
parently not  sick,  who  can  converse  clearly,  keeps  track  of  days  ar 
current  events,  yet  seems  unwilling,  though  really  unable,  to  do  ar;y- 
thing. 

A  young  man  of  21  was  in  the  second  year  of  college.  He  had  always  been 
very  sincere,  serious,  conscientious,  and  applied  himself  very  studiously  to  his 
lessons.  He  had  always  been  interested  in  debating,  but  this  usually  meant  a 
great  struggle  between  the  things  his  intellect  prompted  him  to  say.  and  hi.^ 
self-consciousness  which  hindered  him  from  doing  so.  After  a  period  of  long 
preparation  for  the  critical  debate  of  the  year,  he  had  been  given  the  major 
part  for  his  side.  Being  suddenly  overcome  with  self-consciousness,  he  made  a 
fizzle  of  his  speech  and  lost  the  debate. 

From  then  on  he  felt  different.  He  was  never  able  to  concentrate  on  his 
work,  so  that  he  did  his  lessons  but  very  poorly.  He  was  very  self-reproachful 
over  this,  but  seemed  unable  to  remedy  it.  He  was  troubled  by  frequent  attacks 
of  drowsiness  and  his  head  ached  frequenth'.  His  inability  to  concentrate  or 
to  carry  out  any  plans  continued  to  be  a  source  of  discouragement  to  him,  and 
he  was  able  only  to  spend  his  time  in  reminiscences  and  idle  planning. 

The  type  remains  simple  and  recovery  may  take  place,  as  long  as 
no  fantastic  changes  have  developed.  That  is,  as  long  as  it  has  not  en- 
tered any  of  the  following  phases.  So  that  for  practical  purposes  we 
might  speak  of  two  types  of  Dementia  Precox : 

(i)     Without  fantastic  developments 

(2)     With  fantastic  developments 

The  remaining  types  are  commonly  spoken  of  specifically  and  are 
hence  described. 

(h)     Hebephrenic  Type 

This  reaction  type  is  characterized  by  inability  to  concentrate  on  any 
mental  work  and  by  an  exaggeration  of  his  usual  traits  with  affectation, 
superciliousness,  or  silly  behavior.  There  is  deterioration  and  develop- 
ment of  many  odd  ideas  and  actions  without  the  appearance  of  either 
the  catatonic  or  paranoid  reactions. 


MKNTAL  DISORDERS  .  3 1 

PROGRKSS  OF  THE  DISEASE. 

As  the  disease  procuresses  we  l)egin  to  get  a  more  sinister  picture. 
Here  hallucinations  may  a])pear,  i.  e.,,ima.i^ination  of  seeing  visions  or 
hearing  voices;  or  delusions,  i.  e.,  false  ideas  which  the  patient  seems 
Luiahle  to  correct  in  spite  of  abundant  proof  to  the  contrary,  viz.,  he 
'  may  imagine  his  body  has  become  an  empty  shell,  or  that  he  is  in- 
fluenced to  act  one  way  or  the  other. 

He  may  see  God  in  a  vision  or  talk  with  Him,  or  he  may  feel  him- 
self gifted  with  divine  power  or  entrusted  with  a  diA'ine  mission. 

He  may  make  many  curious  remarks  which  to  him  contain  manifold 
hidden  meanings,  or  he  may  have  a  certain  symbolic  mark  he  puts 
upon  everything,  indicating  that  this  contains  great  hidden  significance. 

On  the  other  hand  sudden  yelling  or  violence  or  an  attempt  to  es- 
cape may  be  carried  on  as  a  result  of  an  inward  prompting  to  make 
some  heroic  effort  and  avoid  some  imagined  catastrophe. 

Complicating  any  of  the  above  he  may  enter  either  of  the  following 
states : 

(c)     Catatonic  Type  or  Catatonic  State. 

This  generally  has  a  gradual  development  such  as  described  under 
Simple  Type. 

This  catatonic  state  is  characterized  by  a  condition  of  muscular 
rigidity,  the  opposing  sets  of  muscles  being  kept  taut  and  tense,  and 
the  limbs  being  held  rigid.  This  muscular  tension  is  so  persistent  that 
it  gives  a  certain  "waxy  flexibility"  to  the  arms  or  legs ;  that  is,  if  an 
arm  of  the  patient  be  lifted  up  by  someone  and  held  in  an  outstretched 
position  for  a  minute  or  so,  then  let  go,  it  may  be  maintained  in  this 
position  for  some  minutes — often  far  beyond  the  time  a  normal  person 
would  be  able  to  maintain  it  in  this  position. 

The  rigidity  seems  to  be  an  abortive  sort  of  resistance  on  the  part 
of  the  patient  against  the  disorder,  perhaps  against  an  indefinite  some- 
thing. Unfortunately  this  may  be  exhibited  as  resistance  to  the  per- 
son who  is  trying"  to  minister  to  his  maintenance.  (Sometimes  when 
the  patient  refuses  food  and  drink,  etc.,  it  seems  a  definite  attempt 
towards  suicide,  as  is  borne  out  by  other  remarks  and  actions.)  It  may 
be  that  this  is  an  attempt  to  imitate  the  prenatal  quiescence.  Many 
other  characteristic  symptoms  have  been  noted,  among  them  mutism  or 
refusal  to  talk,  stereotypic  or  stereotyped  movements  which  are  re- 
♦  peated  over  and  over  and  over  hundreds  of  times  w4th  a  machine-like 
persistence. 

There  is  the  so-called  Catatonic  Stupor,  in  which  the  patient  lies 

•    rigid,  motionless  in  bed,  day  in,  day  out,  night  in,  night  out,  refusing 

to  empty  his  bladder  or  allow  his  bowels  to  move.     xA.ll  functions  have 

to  be  carried  out  artificially — feeding  is  done  by  a  tube,  urine  obtained 


^2  MENTAL  DISORDERS 

by  catheter,  etc.  The  patient  is  by  no  means  in  a  stupor,  though ;  and 
perception  and  memory  are  thoroughly  keen  and  alert.  This  is  demon- 
strated by  occasional  remarks  of  the  patient  which  show  that  he  has 
taken  in  all  that  has  been  said  or  done  in  his  presence ;  or  when  at  some 
later  date  the  disorder  seems  to  clear  up  for  a  time,  and  the  patient 
talks  normally,  and  explains  his  experiences  and  behavior  while  in  the 
previous  immobile  state. 

There  is  also  the  stage  of  Catatonic  Excitement  in  which  the  patient 
screams  or  suddenly  does  impulsive  peculiar  things.  He  may  sud- 
denly get  up  and  jump  out  of  the  window,  or  smash  something,  or  hit 
someone.  He  may  lie  screaming  for  hours.  Though  to  superficial  ob- 
servation he  apparently  cannot  be  reasoned  with,  the  key  to  the  situa- 
tion seems  to  be  that  he  acts  in  this  way  in  response  to  an  inner  com- 
mand or  conviction.  Perhaps  he  hears  an  imaginary  voice  telling  him 
to  act  in  this  way — a  message  from  God  perhaps. 

The  patient,  a  young  man  of  21,  always  bright,  an  honor  man  at  college, 
sensitive,  idealistic,  went  through  an  experience  which  he  described  as  feeling 
like  a  "block  in  thought."  He  finally  passed  into  the  following  condition.  He 
lay  rigid  in  bed  with  eyes  closed.  He  would  not  answer  when  spoken  to  except 
occasionally  to  speak  of  his  own  unworthiness.  He  would  not  swallow  food 
when  it  was  put  into  his  mouth,  and  had  to  be  fed  by  tube.  His  whole  reaction 
was  a  means  of  resistance  to,  or  protest  against,  something  in  his  situation,  as 
shown  by  the  fact  that  he  at  times  tried  to  throw  himself  out  of  bed  on  to  the 
floor  on  his  head.  With  the  exception  of  some  remissions,  when  he  would  be 
lip — though  even  then  standing  rigid — he  continued  in  this  catatoni:;  condition, 
being  tube-fed  and  physically  cared  for.  and  after  some  months  died. 

(d)     Paranoid   Dementia   Precox. 

This  type  as  a  rule  shows  some  premonitory  symptoms,  but  there 
may  be  a  sudden  onset  with  at  once  the  appearance  of  this  fully 
developed  picture.  This  type  is  characterized  by  the  fact  that  the 
patient  presents  delusions  of  grandeur  or  persecution  which  are  more 
or  less  systematized.  It  presents  paranoia  plus  deterioration.  Usually 
he  considers  that  someone  is  definitely  working  against  him,  perhaps 
intending  to  poison  him  or  kill  him  in  some  other  way.  He  may  think 
someone  is  putting  poison  in  his  food  and  then  refuse  to  eat  or  drink. 
This  is  usually  a  serious  sign.  He  often  thinks  everyone  he  knows 
is  con^bined  in  a  "ring"  against  him.  It  seems  as  if  the  patient 
thought  that  his  mental  difficulty  arose  because  some  individual  is 
influencing  him  through  electricity,  mesmerism,  telepathy,  wire- 
less telegraphy,  or  practically  any  invisible  influence  that  he  ,has 
heard  of. 

If  he  hears  voices,  they  may  belong  to  a  certain  person  who  is  thus 
directing  him.  Or  these  voices  may  call  him  names  or  talk  slander- 
ously of  him.  He  refuses  to  refer  his  condition  to  his  own  disintegra- 
tion or  confusion  but  projects  it,  that  is,  he  blames  someone  else  for 
his  inability  to  think.  The  patient  may  get  very  angry  at  this  [>erson 
or  persons  he  supposes  are  controlling  him,  and  try  to  annihilate  them. 


MENTAL   DISORDKKS  33 

Therein  lies  the  danger  from  these  eases.  Always  while  they  are  at 
large  these  patients  are  potentially  dangerous.  1  lence  the  necessity  of 
permanent  institutional  care. 

Paranoid  Dementia  Precox  is  differentiated  from  ordinary  l*aranoia 
by  the  presence  of  deterioration,  and  often  also  of  hallucinations.  In 
true  Paranoia  there  is  apparently  no  other  mental  impairment  outside 
of  the  delusions  themselves. 

The  patient,  aged  26,  was  a  yonng  Jewish  man,  the  son  of  p<jor  immigrant 
parents.  The  patient  was  idealistic,  and  strove  in  every  way  to  improve  the 
family  situation,  being  especially  attached  to  his  mother  and  she  to  him.  He 
early  studied  law,  l)ut  went  to  work  as  a  stenographer  for  the  B.  &  O.  He 
managed  thus  to  help  his  family,  and  they  moved  from  the  slums  to  a  nice 
house  near  the  park. 

After  being  with  the  B.  &  O.  some  months  he  was  discharged.  (  Possibly  his 
deterioration  had  begim. )  He  explained  this,  saying  that  a  request  had  come 
for  criticisms  of  the  railroad  management,  and  he  had  written  a  letter  to  Presi- 
dent Willard,  stating  that  many  office  employees  were  doing  only  nominal  work. 
He  never  received  an  answer,  and  concluded  from  the  actions  of  those  abour 
him  that  his  letter  had  been  referred  back  to  his  department  head,  that  he  had 
been  regarded  as  a  trouble-maker;  and  that  for  this  reason  he  was  discharged. 

For  one  and  a  half  years  following  he  tried  to  secure  a  position  but  was  un 
able  to,  though  he  saw  many  young  men  of  no  greater  ability  l)eing  given  jobs. 
Hence  he  concluded  that  the  B.  &  O.  were  trying  to  keep  him  from  securing  a 
position.     (This  seems  as  if  his  capacity  for  work  had  suifered  a  severe  change- 
recognized  by  everyone  but  himself.) 

He  then  decided  to  go  to  Hopewell,  Va.,  but  took  the  wTong  boat  down,  he 
thinks  due  to  his  having  been  influenced  by  someone.  On  arrival  he  was  given 
bare  living  quarters ;  also  he  saw  some  men  who  he  thought  were  detec- 
tives shadowing  him.  And  so  he  concluded  that  the  munition  makers  were  in 
league  with  the  B.  &  O.  against  him.  Whenever  a  whistle  blew,  it  was  to  make 
his  conscience  trouble  him. 

He  returned  home  and  for  five  nights  lay  awake  until  he  Anally  saw  that  for 
years  an  influence  had  been  working  against  him. 

At  times  a  black  spot  was  made  to  fall  about  him  as  he  worked  which  his 
fellow-men  could  see.  He  would  have  a  vision  of  a  certain  figure  before  him. 
All  this  was  due  to  a  scientific  optical  illusion  brought  about  by  the  same  con 
spiracy  against  him.  Moreover,  he  was  made  to  have  seminal  emissions  by  the 
same  power,  heard  voices  speaking  in  his  ear.  and  was  troubled  by  visions  of  all 
manner  of  lewd  sexual  imagery. 

After  some  months  of  this  paranoia,  plus  inability  to  concentrate,  he  became 
vengeful  and  wanted  no  one  to  enter  his  house.  He  threatened  everyone  who 
came  in.  His  family  considered  him  so  dangerous  that  they  had  him  confined 
to  an  institution. 

I  would  impress  upon  the  reader  the  fact  that  the  above  so-called 
types  are  merely  varying  phases  of  one  and  the  same  very  complicated 
emotional  disturbance,  and  that  the  distinctions  betw^een  them  at  best 
are  but  very  crude.  The  descriptions  of  all  four  should  be  taken  to- 
gether as  the  description  of  one  entity.  By  reading  them  several  times 
together,  common  characteristics  and  a  general  relationship  will  grad- 
ually appear  so  that  when  one  type  is  seen,  the  possibilities  of  all  other 
types  will  be  kept  in  mind. 


34  MKNTAL  DISORDERS 

DISCUSSION  OF  CAXTSES  OF  DEMENTIA  PRECOX. 

The  theories  to  account  for  Dementia  Precox  are  of  two  kinds. 

1.  The  first  type  holds  that  the  symptoms  of  mental  disturbance 
as  shown  by  unusual  speech  and  actions  are  the  result  of  a  toxine  acting 
on  the  cortex,  or  of  actual  changes  taking  place  in  the  cortex  itself, 
either  toxine  or  physical  change  being  too  subtle  to  be  demonstrated 
by  our  present  laboratory  methods.  Abnormal  secretion  on  the  part 
of  the  thyroid,  adrenal,  or  the  chromaffin  system  have  been  suspected, 
also  gliosis  of  the  cortex. 

All  that  can  be  said  for  such  a  theory  is  that  as  yet  nothing  definite 
has  been  demonstrated ;  though  no  doubt  all  would  hail  such  a  dis- 
covery with  great  satisfaction. 

2.  The  second  theory  is  that  mind  or  mental  processes  can  suffer 
a  deterioration  of  themselves  through  faulty  mental  habits  or  faulty 
development  of  instincts,  or  by  being  inhibited ;  that  is,  that  there  can 
be  a  functional  deterioration  of  the  mind  itself. 

The  discoveries  in  the  realm  of  the  subconscious  tend  to  show 
that  such  a  theory  is  possible ;  discoveries  such  as  the  capacity  of  the 
subconscious  for  retaining  memories  and  for  combining  memories  into 
plans  or  inventions  :  and,  on  the  other  hand,  the  inhibition  of  thought 
activity,  the  inhibition  of  the  combination  of  images  into  plans  and 
the  inhibition  of  the  conversion  of  plans  into  action,  by  constellations  of 
painful  memories,  which  may  take  place  within  its  borders. 

It  is  a  theory  of  the  functional  development  of  Dementia  Precox 
which  we  ourselves  wish  to  offer  for  consideration,  not  taking  issue 
with  any  other  theories  of  the  causation  of  Dementia  Precox  but 
merely  attempting  to  explain  its  development  for  a  certain  and  perhaps 
restricted  group  of  cases. 

The  theory  here  maintanied  m  brief  is  this :  The  main  feature  of 
Dementia  Precox  is  that  referred  to  as  "deterioration"  or  "block  in 
thought,"  i.  e.,  the  inability  to  concentrate,  and  all  other  symptoms  such 
as  mysticism,  religious  tendencies,  symbolism,  sterotypie,  are  conse- 
quent upon  this  interference  with  thought  activity ;  and  this  thought- 
blocking  itself  is  due  to  a  multiform  and  overwhelming  inhibition 
arising  within  the  patient's  subconscious. 

As  to  the  fantastic  symptoms  being  secondary  to  the  thought  inter- 
ference, we  can  see  that  religious  cjuotations  invariably  refer  back  to  a 
lack  of  mental  activity  in  the  person  who  quotes,  in  this  case  the  patient. 
It  is  always  easier  to  quote  than  to  formulate  the  situation  in  words  for 
one's  self.  And  as  Biblical  quotations  form  many  of  our  earliest  and 
most  lasting  and  most  significant  memories,  when  our  own  words  fail 
us  in  describing  a  situation,  we  reach  into  a  memory  pigeon-hole  and 
pull  out  a  Bibhcal  quotation  to  fit.  Religious  behavior  is  likewise 
the  result  of  scarcity  of  ideas  for  individual  action ;  though  the  col- 


MENTAL   DISORDERS  35 

ori ng  of  the  religious  behavior,  whether  it  be  ecstasy  or  abasement  or 
union  with  God,  may  perhaps  be  varied  by  emotional  factors  already 
present.  Stereotypic  is  certainly  a  result  of  lack  of  new  ideas.  Sym- 
bolism is  much  like  Biblical  quotations  in  that  it  is  the  application  of 
a  borrowed  means  of  description  in  place  of  making  one's  own  articulate-, 
expression. 

In  this  wa\'  all  fantastic  developments,  even  hallucinations  and  delu 
sions,  perhaps  may  be  a  result  of  the  thought  blocking.     The  latter  is 
then  the  central  feature  of  the  whole  picture  and  the  one  which  we 
wish  to  study  further. 

This  blocking  of  thought  we  regard  as  a  profound  confusion,  a  ver\ 
extensive  inhibition,  analagous  to  the  milder  inhibitions  such  as  "stage 
fright,"  lapses  of  memory,  or  repressions  giving  rise  to  the  presence 
of  delusions. 

The  development  of  this  blocking  is  the  result  of  millions  of  experi- 
ences dating  possibly  from  the  patient's  birth. 

A  little  more  fully  stated  the  thesis  is  that  the  human  mind,  sub- 
conscious and  conscious  taken  together,  at  infancy  is  like  a  very  sensi- 
tive plant.  An  unsympathetic  environment  which  does  not  constantly 
encourage  its  growth,  and  more,  an  outspokenly  aggressive  environ- 
ment, acts  on  this  sensitive  plant  causing  many  painful  experiences  and 
memories.  These  in  turn  inhibit  the  growth  of  the  delicate  tendril-like 
processes  of  the  mind  and  distort  the  final  growth  of  the  individual. 
Or  expressed  differently,  the  mind  of  the  person  is  inhibited. 

Thus  as  people  grow  up  we  get  all  grades  of  inhibition  from  the 
^'normal"  person  whose  artistic  capacities  and  means  of  self-expression 
are  hopelessly  tied  up,  through  the  more  inhibited  types,  the  shy,  the 
diffident,  the  person  who  is  too  inhibited  to  carry  on  the  average  life, 
to  the  still  more  inhibited.  Now  as  the  inhibition  reaches  an  over- 
whelming degree  we  say  the  patient  has  Dementia  Precox  and  the 
actions  resulting  from  his  inhibited  mental  processes  we  call  the  symp- 
toms of  the  disease.  There  are  mild  types  of  the  disorder,  'simple 
deterioration,"  and  a  gradation  all  the  wa\  to  the  very  serious  disso- 
ciation of  mental  processes  or  deterioration  which  rapidly  ends  in  death. 

Let  us  illustrate  by  still  further  detail. 

THE  SITUATIOX. 

Reducing  the  question  to  its  simplest  terms,  it  seems  that  wlicn  we 
analyze  each  of  the  various  reaction  complexes  grouped  under  the 
caption  of  Dementia  Precox  or  Schizophrenia,  we  come  upon  essen- 
tially the  same  underlying  human  drama. 

First  we  find  that  the  individual  has  always  been  somewhat  diiterent 
from  his  fellows.  He  has  belonged  to  the  "shut  in"  type  described  by 
Tung.  Instead  of  playing  in  the  carefree,  boisterous  way  of  many 
diildren,  he  has  been  shy  and  retiring,  abhorring  strife,  very  sensitive 


36    ■  MENTAL  DISORDERS 

to  perhaps  music  and  colors  and  the  beauties  of  nature,  all  of  those 
things  which  we  find  in  aduk  life  to  be  the  stimulus  to  the  artist.  Being 
different  from  his  acquaintances,  he  has  but  few  confidants,  possibly 
he  has  one,  but  here  the  friendship  may  be  very  intense.  Abhorring 
strife  and  the  competition  of  children's  groups,  he  keeps  much  alone; 
in  fact,  he  feels  most  at  ease  when  alone.  It  is  a  question  if  he  is 
properly  called  the  "shut  in"  type.  He  might  perhaps  be  better  de- 
scribed as  being  "driven  in"  on  himself — an  introverted  personality. 
This  may  all  be  covered  by  an  assumed  shell  of  outer  hardness,  but  is 
apparent  in  varying  degrees. 

Many  of  these  young  people  are  intuitively  altruistic  and  over-con- 
scientious and  responsible.  They  may  carry  the  burdens  of  the  world 
upon  their  young  shoulders,  they  may  be  filled  with  schemes  to  im- 
prove life  for  many  people,  world  improvement  schemes,  profundities 
to  which  most  people  have  grown  callous  with  time.  They  are  often  the 
over-sensitive,  the  over-gentle,  the  super-kind. 

One  gains  the  impression  with  many  cases  of  Dementia  Precox  that 
there  are  countless  unexpressed  desires  and  impulses  wdiich  are  grop- 
ing blindly  for  a  way  of  expression,  but  never  find  it.  In  fact,  the  very 
inarticulateness  is  one  of  the  most  striking  characteristics  of  Dementia 
Precox. 

As  a  second  factor  in  the  development  of  Dementia  Precox,  we  have 
this  sensitive,  gentle,  inarticulate  person  meeting  an  environment 
which  to  him  means  death  itself,  death  to  the  growth  of  nezi'  ideas, 
unusual  hopes,  "long,  long  thoughts,"  which  we  know  are  characteristics 
of  youth  and  childhood. 

COURSE 

To  begin  with,  the  play  of  children  and  their  treatment  of  each  other 
is  characterized  by  keen,  struggling,  almost  cruel  competition.  The 
domination  of  one  child  by  another,  the  hostile  criticism  and  teasing 
of  one  child  by  one  or  all  the  others,  brings  the  greatest  pain  to  this 
quiet,  gentle  type. 

Then  schools  are  manifestations  of  competition,  the  upper  classes 
against  the  lower,  the  older  boys  against  the  younger,  the  strong  against 
the  weak.  It  must  be  confessed  also  that  where  all  should  be  toler- 
ance and  patience  and  encouragement,  i.  e.,  at  the  hands  of  the  teach- 
ers, there  is  often  arbitrary  treatment.     This  has  been  well  described : 

"It  seems  to  me  that  in  our  present  mechanical,  unimaginative  routine  of 
'instruction'  based  upon  exclusive  objective  ideals,  we  have  an  example  of  what 
may  be  called  the  'institutional  neurosis.'  The  genus  'school  ma'am.'  conjuring 
visions  of  an  austere,  puritanical  female,  policing  formal  rows  of  intimidated  chil- 
dren, affords  us  a  familiar  clinical  symptom  of  this  institutional  form  of  re- 
pression. In  the  typical  preceptor  with  his  overzealous  emphasis  upon  stricture 
and  discipline,  the  psychoanalyst  suspects  that  the  real  motive  is  some  secret 
discomfiture — some  hidden  discrepancy  in  the  life  of  the  teacher  himself.     And, 


MENTAL   DISORDERS  37 

in  realitv,  upon  analysis,  we  find  within  him  an  overwcaning  desire  to  assert 
his  own 'will,  to  coerce,  to  restrict,  to  repress  the  spontaneity  of  others.  His 
libido  has  been  deflected  from  its  primary,  affectional  sphere,  to  a  regressive, 
sadistic  plane.  Following"  the  introversion  attendant  upon  his  own  disappoint- 
ment, the  contemplation  of  childhood  fills  him  with  l)itternoss  and  pain,  and  in 
truth  the  motive  that  draws  such  an  individual  to  the  career  of  teaching  is,  only 
too  often,  an  unconscious   resentment."* 

So  that  this  child  feels  himself  overlaid  by  layer  upon  layer  of  more 
or  less  hostile  people,  older  than  himself  in  years,  and  stronger  in  the 
power  to  hurt  and  make  life  miserable  for  him. 

From  within,  too,  come  further  disturbing  factors  which  conflict 
with  what  he  has  been  taught. 

It  is  perhaps  not  exaggerating  to  state  that  only  in  the  exceptional 
case  a  child  has  his  questions  answered  and  is  told  freely  and  frankly 
and  wholly  about  many  things.  But  especially  rarely  is  he  told  about 
sex  and  all  its  manifold  and  far-reach,ing  radiations.  Rather  the 
attempt  is  made  to  brush  any  knowledge  or  ideas  of  sex  completely 
out  of  his  consciousness  and  out  of  his  world.  He  is  taught  that  he 
should  not  think  of  it,  much  less  know  of  it,  and  that  there  is  some- 
thing shameful  connected  with  the  whole  subject.  It  is  a  subject  on 
which  there  should  be  no  thought.  And  yet  every  child  has  some 
glimmering  of  sex  consciousness,  some  vague  curiosity  concerning  sex 
and  creation,  which  seem  incontrovertible,  natural,  and  not  only  right, 
but  beautiful. 

Again,  perhaps  the  strongest  influence  of  all,  come  the  child's  par- 
ents. Many  people  see  sometimes  that  the  child  seems  hostile  to  his 
parents,  but  often  what  is  more  truly  the  case  is  not  seen,  namely,  that 
parents  are  hostile  at  times  to  their  children.  This  may  be  conscious 
but  it  often  is  not.  Now,  that  this  statement  may  not  seem  quite 
unfounded,  we  might  quote  the  familiar  observation  that  a  mother 
wishes  to  keep  her  children  as  infants,  "tied  to  her  apron  strings,"  and 
is  jealous  of  their  becoming  interested  in  other  women. 

Now  this  would  scarcely  seem  hostility  on  the  part  of  the  mother, 
until  the  child  or  youth  no  longer  wishes  to  remain  an  infant  ''tied 
to  the  mother's  apron  strings"  and  then  the  hostility  appears.  By 
having  his  ambitions  opposed  (though  perhaps  not  frankly  so),  hopes 
quashed,  and  desires  for  liberty  curtailed,  he  feels  about  him  an  iron 
wall  against  his  growth.  His  attachment  for  her  also  renders  her 
power  over  him  all  the  more  absolute.  But  this  also  he  has  been 
taught  to  deny. 

The  father-son  rivalry  means  no  less  an  equal  form  of  opposition  to 
the  child.  Though  this  may  come  to  almost  open  warfare  as  the 
youth  begins  to  mature,  in  early  childhood,  and  with  >his  "shut  in" 
personality,  it  exists  chiefly  in  the  form  of  domination  of  the  father 
over  the  child.  We  have  all  observed  those  sires  who  demand  "imme- 
diate obedience,"  who  stress  the  patriarchal  (and  prehistoric)   idea  of 

*Dr.    Trigant    Burrow-:    "Permutations    Within    the    Snhcre    of    Consciousness." 

Jour.   Abn.    Psych.   Aug.-Sept.    1916. 


^8  MENTAL  DISORDERS 

the  dntv  of  the  child  to  his  parents,  ignoring  of  course  the  duty  of 
parents  to  their  children  ;  and  we  have  perhaps  deplored  many  times 
the  lot  of  those  children  who  must  give  in  to  them  in  many  unneces- 
sary acts  of  discipline  and  almost  slavery. 

But  perhaps  the  less  obvious  and  for  this  reason  the  more  deadly  are 
those  fathers  who  do  not  oppose  their  children  openly  (for  then  such 
children  often  develop  into  open  rebellion  and  thence  freedom),  but  do 
so  in  less  apparent  ways.  A'iz.,  when  creative  desires  are  derided,  and 
those  very  sensitive  subjects,  early  creative  attempts,  are  made  light 
of,  treated  as  childish  vagaries  instead  of  the  development  of  person- 
ality, or  treated  with  cold,  absolute  indifference. 

Or  parents  may  have  their  conventional  ideas  as  to  what  people  should 
be,  and  try  to  compress  these  growing  spirits  to  fit,  to  make  a  bush 
into  a  fence  post,  a  Pegasus  into  a  cart  horse. 

The  minds  and  interests  and  possibilities  of  children  are  so  little 
understood  by  their  elders  and  the  children  are  so  often  discouraged 
by  the  obstacles  set  before  them,  composed  of  the  lack  of  understanding 
of  their  elders,  that  by  the  time  the  children  reach  adolescence,  all  spon- 
taneity and  originality  has  been  pressed  out  of  their  consciousness. 
It  is  fair  to  state  that  of  all  children,  the  majority  are  prevented  by 
their  parents  from  developing  to  their  greatest  capacity.  It  is  a  very 
rare  thing  that  an  interest  in  a  child  is  strong  enough  to  overcome  the 
opposition  thus  set  up  by  the  parents. 

As  Dr.  Meyer  puts  it :  • 

"The  greatest  difficult}-  in  life,  the  greatest  source  of  disharmony,  (apart 
from  the  influences  of  heredity,  infectious  disease,  and  poor  feeding,  and  poor 
chances  for  growth,)  is  the  discrepancy  between  impulse,  yearning  and  ambition 
on  the  one  hand  and  the  actual  opportunities  and  actual  efficiency  of  performance 
on  the  other." 

The  child,  no  doubt,  seldom  formulates  this  in  his  mind.  The  great- 
est tragedy  is  that  the  situation  does  not  get  to  his  consciousness.  He 
is  just  disturbed  without  knowing  why.  Conscious  wants  may  be 
agonizing,  particularly  when  active.  As  an  artistic  friend  once  wrote : 
**To  want  to  do,  and  to  remain  passive :  to  want  to  express,  and  to  re- 
main mute.    This  is  perhaps  the  keenest  suffering." 

And  yet  here  the  want  is  at  least  conscious ;  we  know  what  it  is  we 
want.  But  there  are  still  deeper  wants  of  which  we  are  not  conscious ; 
when  we  want  for  something  and  do  not  know  what  it  is.  This  latter 
kind  of  want  is  the  most  disturbing  as  it  is  the  least  definite.  Its  verv 
uncertainty  adds  bulk  and  distress. 

The  inarticulateness  of  the  whole  situation  of  Dementia  Precox,  the 
vagueness  of  the  factors,  the  fact  that  much  of  it  goes  on  below  the 
level  of  the  patient's  clear  consciousness,  shows  the  deplorable  state  o1 
a  present  day  education  which  grants  such  a  small  degree  of  con- 
sciousness to  those  within  its  domain. 


MENTAL   DISORDERS  39 

Now  the  child  is  very  largely  the  resultant  of  the  compression  put 
upon  him  by  his  environment,  for  his  spirit  is  young,  and  tender,  and 
plastic,  and  he  is  just  one  alone;  whereas  his  environment  is  old,  and 
set,  and  adamantine,  and  infinite.  If  a  young  plant  be  prevented  from 
growing  in  one  direction  by  a  stone  set  beside  it,  it  can  grow  but  in 
three  directions  ;  if  it  have  a  stone  on  two  sides  of  it  it  can  grow  \ut  in 
two  directions  and  upwards.  But  if  a  great  stone  be  set  on  top  of  it, 
it  will  grow^  greatly  distorted,  or  it  will  not  grow  at  all. 

And  so  it  is  with  the  spirit  of  children.  They  present  all  gradations 
of  impaired  development.  Some  personalities  hit  off  a  compromise 
between  what  they  desire  and  what  is  desired  of  them,  and  become 
the  usual  ordinary,  much  inhibited,  unoriginal  person ;  others  become 
hard  and  fight  their  way  through  to  liberty,  but  they  always  carry  scars 
of  this  fight  with  them  thereafter,  and  even  pieces  of  their  hardness 
like  bits  of  armor,  which  often  surprise  us  years  later  by  suddenly  ap- 
pearing in  unexpected  places.  Now  the  individual  variation  among 
various  young  spirits  here  enters  ;  the  reaction  is  not  alone  due  to  the 
impress  of  the  environment,  but  the  constitutional  make-up  of  the 
person  determines  to  a  certain  extent  also  the  result.  The  "shut  in" 
or  more  properly  ''driven  in"  or  the  pre-Dementia  Precox  type  is  too 
gentle,  too  kindly  to  fight.  The  stone  placed  upon  him  is  too  great.  His 
spirit  cannot  push  it  aside,  and  being  thus  pressed  upon,  it  can  only 
grow  distorted. 

At  adolescence,  the  child  is  overwhelmed  by  a  surge  of  feelings  and 
desires  and  vague  longings,  which  bring  varying  amounts  of  shameful- 
ness  according  to  his  training  and  which,  strive  as  he  might  he  finds 
himself  unable  to  drive  from  his  consciousness. 

Though  this  is  the  period  of  budding  forces  he  does  not  know  what 
he  is  interested  in,  what  are  hence  his  fortes,  what  line  to  follow.  He 
wants  to  do  growing,  budding,  increasing  things.  Having  been  forced 
for  years  outwardly  to  conform,  he  finally  is  unable  to  do  otherwise. 
But  only  outwardly.  The  universal  spirit  within,  full  of  spontaneity, 
interests,  far-reaching  visions,  will  not  and  cannot  be  denied.  His 
spirit  is  too  new,  too  soft  and  bud-like  as  yet  to  fight  its  way  out  to 
a  clear  view  of  the  situation.  In  many  ways  he  will  be  much  attached 
to  his  parents,  and  there  will  be  great  conflicts  in  him  between  wishing 
to  be  as  they  mould  him,  to  think  as  they  direct,  to  try  to  deny  those 
ideas  upon  which  they  have  placed  the  sign  "forbidden."  and  his 
inward  conviction  of  what  is  true  and  there-fore  right,  the  path  which  his 
spirit  points  out  for  him  to  follow.  In  fact,  it  is  this  very  morality,  this 
wish  to  obey  those  parents,  as  opposed  to  wdiat  his  sense  of  truth  and 
justice  tells  him,  that  causes  the  confusion  :  that  is  what  Burrow  means 
when  he  says  that  it  is  ''an  organic  morality''  that  fonms  the  basis  of 
the  mental  disorder. 


40  MENTAL  DISORDERS 

RESULT^ 

Life,  real  life,  mental  life,  is  composed  of  stimuli — inspirations, 
thou.f;hts,  ideas — received  and  transmitted  into  acts.  When  these 
thoughts,  too  great  for  expression  or  even  consciousness,  struggle  for 
expression  and  action,  and  this  action  is  prevented,  we  get  a  distortion 
of  the  spirit  and  of  the  personality.  This  disorder  of  all  the  impelling 
and  expressive  factors  of  the  personality  in  the  extreme  case  are  what 
become  known  to  us  as  the  symptoms  of  Dementia  Precox. 

THE  CHANGE. 

The  change  in  the  individual  becomes  at  last  obvious,  and  there  is 
present  an  interference  with  the  course  of  normal  thought  action,  an 
inability  to  do  the  usual  work,  to  think  clearly.  In  an  intelligent  intui- 
tive person  it  is  felt  as  a  definite  *'block  in  thought" — a  certain  some- 
thing stops  his  flow  of  mental  images  and  means  of  expression.  A  less 
intelligent  person  may  adduce  reasons  of  his  own  for  his  behavior — he 
may  ''reason  as  he  does."  Owing  to  the  automatic  nature  of  behavior 
these  factitious  reasons  must  be  separated  off  from  the  picture. 

A  still  less  intelligent  person  projects  it  on  to  persons  around  him  and 
asserts  that  a  "spell  is  put  upon  him,"  *'he  is  hypnotized,"  "electricity  is 
sent  through  him,"  etc.  This  may  take  place  very  rapidly  with  marked 
excitement  and  appearance  of  fear,  as  if  the  change,  though  l)ut  dimly 
sensed,  had  frightened  the  person.  This  may  often  be  the  basis  of  the 
Dementia  Precox  excitement  and  violence. 

The  catatonic  has  reacted  to  this  feeling  of  sudden  deterioration  by 
trying  to  fight  it,  the  muscular  tension  and  active  resistance  being 
merely  an  evidence  of  the  inward  opposition  to  this  unaccountable  loss 
of  capacity.  Excitement  and  violence  may  also  be  a  sign  of  opposition 
to  this  ovcrwhelnnng  change. 

One  type  of  person  mentally  puts  himself  back  in  his  mother's  womb 
to  gain  comfort  that  way  and  be  new  born ;  to  be  "born  again"  in 
order  to  return  refreshed  from  this  inability  to  think. 

Another  runs  to  religion  and  belief  in  God  in  just  the  same  way — 
(something  stronger,  all  powerful,  an  ever-present  help  in  time  of 
trouble).  Christ  may  be  the  Mother  image,  and  being  Christ  is  bemg 
the  mother  or  being  with  her.  For  lack  of  ability  to  formulate  and 
express  his  puzzlement,  he  idly  places  symbol  after  symbol  in  a  line 
across  the  page. 

All,  in  short,  are  seen  to  show  more  or  less  distinctly  a  feeling  of 
sudden  loss  of  capacity,  the  individual  reaction  to  this  differentiating 
the  dift'erent  types.  The  patient  is  completely  overwhelmed  by  the 
storm  arising  within  his  subconsciousness.  The  inward  conflict  be- 
tween the  desires  he  feels  to  be  present  and  the  teachings  of  his  en- 
vironment to  the  contrary,  i.  e.,  the  social  repression,  between  his  dif- 
fident hopes  and  memories  of  harsh  experiences  in  attempting  to  real- 


MFCNTAL   DISORDERS  "  4I 

ize  them,  causes  his  attention  to  be  turned  from  the  outside  world  in 
upon  himself;  his  attention  becomes  introverted.  He  turns  from  a 
world  which  is  practical,  unsympathetic,  painful,  into  the  world  of 
his  own  thoughts  wdiere  no  discordant  criticism  is  raised,  no  dreams 
forbidden. 

His  attention  being  little  in  the  world  about  him,  his  behavior  towards 
it  becomes  purposeless,  haphazard,  and  casual.  He  reverts  to  the 
easiest  adaptation  to  it  or  form  of  behavior  he  has  memory  of,  infan- 
tile or  almost  automatic  action;  perhaps  he  reverts  even  to  the  prena- 
tal form  of  behavior,  wherein  he  is  nourished,  warmed  and  clothed, 
all  with  no  movement  or  effort  on  his  part.  Thus  we  see  why  he  keep*^ 
to  himself,  why  he  wants  to  be  let  alone,  to  live  in  revery,  to  cease 
from  every  form  of  activity.  At  last  in  the  aberrant  reactions  ol 
Dementia  Precox  he  has  found  a  long  sought  and  eternal  peace. 

Truly  did  the  old  Cireeks  say,  "Those  whom  the  Gods  love  (i.  e.. 
the  kindly,  the  gentle,  the  loyal)  die  young." 

Thus  we  see  that  in  some  cases  the  so-called  Dementia  Precox  is. 
like  the  neuroses,  a  disorder  which  arises  in  a  certain  type  of  person 
as  a  result  of  a  certain  type  of  treatment  accorded  him  by  the  indi- 
viduals forming'  his  environment.  Whv  the  individual  is  so  con- 
structed,  and  why  others  should  treat  him  in  this  way  are  questions 
only  to  be  treated  of  in  more  advanced  works. 

A  theor\-  that  shows  us  how  inhibited  states  develop  puts  us  one  step 
on  the  road  toward  preventing  them ;  and  holds  gut  the  hope  to  every- 
one thereafter  of  a  more  full,  more  active,  and  more  conscious  life. 

A  few  of  the  factors  concerned  in  the  causation  of  the  disorder  are 
here  touched  upon ;,  perhaps  the  future  will  bring  to  light  many  more. 

11.    The  Neuroses  or  ''Xervousxess"  of  Apparextly  Well  People. 

These  states  are  quite  diff'erent  from  any  of  the  foregoing.  For  the 
most  part,  they  are  not  apparent  to  anyone  but  the  patient  or  to  those 
who  know  the  patient  well.  The  patient  can  usually  carry  on  his  work 
after  a  fashion  and  physically  looks  well  enough,  he  sleeps  well,  has  a 
good  appetite,  and  has  the  appearance  of  health,  and  a  detailed  medi- 
cal examination  fails  to  reveal  any  physical  basis  for  the  condition. 

Pie  himself,  however,  feels  that  he  is  radically  prevented  from  doing 
his  work  or  acting  or  thinking  with  the  ease  that  he  may  previously 
have  enjoyed.  Pie  may  feel  that  he  gets  fatigued  after  a  very  short 
time,  and  then  feels  "done  up"  for  the  rest  of  the  day,  or  he  is  trou- 
bled by  vague  feeling>^  of  impending  disaster,  or  is  obsessed  by  the 
feeling  that  he  must  viz..  count  every  white  automobile  that  he  sees. 
The  various  symptoms  have  been  grouped  together  and  the  various 
symptom  complexes  designated  as  follows: 


42  MKNTAL  DISORDERS 

I.       NEURASTHENIA. 

The  term,  which  means  Hterally  "nerve  weakness,"  is  appHed  to 
bodily  conditions  which  seem  characterized  by  irritable  debility.  The 
patient  is  easily  fatigued.  He  or  she  has  a  constant  backache  or  head- 
ache, and  very  little  physical  or  mental  activity  is  sufficient  to  increase 
these  aches  to  the  point  that  they  force  him  to  stop  and  rest,  or  lie 
down.  Abnormal  sensations  are  felt,  or  the  reactions  that  normally  do 
not  come  to  consciousness  are  perceived. 

He  may  have  a  pain  which  moves  about  in  the  abdomen  and  travels 
up  to  the  heart,  or  to  various  places  in  the  chest  or  back.  The  normal 
peristaltic  movement  of  his  bowels  may  be  felt  by  him  to  his  constant 
worrv.  Irregular  pains,  backaches,  headaches,  burning  in  the  abdo- 
men, fatiguability ;  symptom  groups  much  like  some  of  the  thyroid 
states  are  characteristic,  hence  the  thyroid  must  be  carefully  inves- 
tigated. 

2.  PSYCHASTHENiA  (psychic  wcakncss)  used  for  conditions  of 

(a)  Obsessive  or  compulsory  thinking  (obsessions)  such  as  a 
feeling  of  compulsion  to  count  the  numbers  of  houses  when  passing  in 
a  car,  a  feeling  that  a  certain  thing  is  so  when  our  better  judgment  tells 
us  it  15  not,  etc.  A  man  may  feel  that  he  has  killed  his  brothci  thotigh 
he  may  know  him  to  be  alive,  etc. 

(b)  Fear  of  some  special  situation  or  object  {phobia).  Fear  of 
open  spaces,  (agarophobia),  fear  of  being  in  a  closed  room  (clau- 
straphobia),  fear  of  dirt  (mysophobia) .  In  the  following  we  see  a 
phobia  and  an  obsession  : 

A  young  woman  of  19  had  been  married  for  a  year  to  a  young  man  of  21. 
In  all  that  time  there  had  been  no  sexual  intercourse  as  the  patient  had  been 
afraid. 

For  six  months  the  patient  had  been  very  fearful  of  contamination  and  solici- 
tous of  washing  her  hands;  she  would  wash  them  every  few  minutes.  If  she 
saw  a  blind  man,  especially,  she  would  turn  right  around  on  the  street,  hurry 
home,  and  wash  her  hands.  She  had  washed  her  hands  so  frequently,  and  with 
such  a  strong  disinfecting  solution  (sulpho-naphthol)  that  they  were  excoriated 
for  large  areas. 

3.  HYSTERIA,  a  very  suggestible  state  in  which  some  intense  idea 
or  emotion  seems  to  result  in  an  impairment  of  some  part  of  the  body, 
such  as  hysterical  paralysis  of  arm  or  leg,  hysterical  blindness,  deaf- 
ness, etc.  These  can  be  readily  detected  by  medical  tests  as  the  neces- 
sary structures  are  still  intact. 

Hysterical  convulsions  also  may  be  the  result ;  and  the  basis  of  many 
cases  of  epilepsy  may  be  hysterical. 

4.     ANXIETY  NEUROSIS  ov  Aiixictx  Status. 

Many  cases  of  Neurasthenia  are  really  cases  of  Anxiety  Status.  The 
two  merge  imperceptibly  and  in  short  arise  virtually  on  the  same  basis 
and  are  the  same  disorder.     The  characteristics  of  Anxietv  Neurosis 


MENTAL   DISORDERS  43 

arc  feeling  of  apprehension,  fear  of  some  vague  impending  disaster; 
perhaps  anxiety  attacks  with  rapid  heart,  breathlessness,  weakness ; 
uorrying,  inabiHty  to  do  one's  best  work. 

Patient,  a  young  man  born  in  a  small  town  in  Virginia.  As  a  boy  always 
shy,  diffident,  and  seclusive,  disliking  rough  games  and  vigorous  sports.  Military 
school  15-16.  but  here  very  much  alone  and  lacking  confidants.  After  a  few- 
months*  business  course  he  went  away  from  home  to  work  in  a  strange  town. 
Here  he  lived  in  the  apartment  of  some  friends  who  were  away. 

Suddenly  one  night  he  had  a  heart  attack — heart  beat  very  fast  and  forcibly, 
and  he  thought  he  was  going  to  die.  For  two  weeks  he  had  several  attacks, 
ajways  accompanied  by  fear.  This  was  erroneously  treated  with  Digitalis  by  a 
local  physician.  After  a  month  of  this  he  began  to  fear  leaving  his  house  or 
yard,  and  was  afraid  to  attempt  going  anywhere  for  fear  of  another  attack. 

Finally  he  took  an  easy  job  in  a  local  bank  where  pistols  were  kept.  Then 
suddenly  he  began  to  think,  "What  if  I  should  kill  myself!"  Four  months  after 
the  original  attack  he  began  to  have  periods  of  depression  in  which  he  would 
cry. 

On  entrance  he  was  co-operative  though  slightly  ill-at-ease  or  anxious.  He 
expressed  himself  as  being  nervous  and  at  times  depressed  and  afraid  to  do  any- 
thing out  of  the  ordinary — afraid  of  going  out  and  among  people,  under  con- 
stant fear  of  killing  himself,  so  that  at  the  sight  of  a  razor  or  knife  or  sharp 
article  in  a  store,  or  on  crossing  a  bridge  he  would  think  of  suicide  and  fear 
he  might  end  his  life. 

Physically  he  was  well ;  his  heart  especially  w^as  normal  in  every  way. 

Course  and  development:  Through  free  associations  and  analysis  of  his  dream 
material,  his  diffidence  and  fear  of  being  with  people  were  traced  to  a  mas- 
turbation complex  and  unrecognized  homogenic  impulses.  IMother  fixation  also 
played  an  important  part.  A  gradual  assimilation  of  these  resulted  in  such  im- 
provement that  he  secured  himself  a  position  and  advanced  himsel  '  from  this 
position  to  a  better  one.  The  depression  disappeared,  and  the  ideas  of  suicidt 
retired  to  the  role  of  mere  fancies. 

DISCUSSION    OF'    CAUSES    OE    NEUROSES. 

Though  it  is,  of  course,  not  known  what  may  be  the  future  discoveries 
in  the  domain  of  the  emotional  disturbances,  nevertheless  the  more 
recent  psycho-analytic  investigations  have  already  shown  us  some  very 
interesting  facts.  In  all  the  neuroses  the  real  trouble  is  not  that  of 
which  the  patient  complains,  or  which  exhibits  itself  as  perhaps  the 
major  feature.  The  difficulty  is  in  reality  at  the  antipodes,  so  to 
speak,  of  the  patient's  personality.  It  lies  not  in  a  bodily  ache,  but  in  a 
mental  conflict.  The  bodily  complaint  or  hysterical  attack  is  ''played 
up"  automatically  by  the  patient  merely  to  take  his  attention  from  the 
greater  trouble,   the   mental   conflict. 

Bernard  Hart's  little  book,  The  Psychology  of  Insanity,  depicts  in  a 
most  engaging  manner  the  common  habit  of  avoidance  of  unpleasant 
thoughts  or  unpleasant  constellations  of  ideas.  These  unpleasant  con- 
stellations usually  represent  mental  conflicts ;  one  part  of  us  wants  one 
thing,  another  part  the  other.  The  struggle  between  the  two  becomes 
so  painful  that  rather  than  step  in  and  take  the  extra  pain  of  settling 
it,  we  avoid  the  whole  subject  altogether  and  try  to  forget  it.  Through 
a  clear  and  simple  explanation  there  is  shown  how  this  conflict  and 
evasion  causes  the  changes  in  the  individual's  personality  known   as 


_|.|  MENTAL  DISOR:;KRS 

the  various  symptoms  of  the  disorder.  Tlie  so-called  symptoms  may 
reallv  be  a  protest  of  the  patient's  subconscious  against  the  life  he  is 
leading  at  the  time. 

Let  us  quote  directly  from  another  author  the  following : 

"Whether  it  is  a  question  of  the  vicarious  impulses  and  imperatives  '^rlouaing 
to  the  obsessional  state  ;  or  of  the  characteristic  somatic  alternatives  of  hysteria ; 
or  of  the  mitigating  substitutions  and  replacements  constitutive  of  paranoid 
mechanism,  or  of  the  organic  equi\  ocations  of  the  anxiety  dissociations;  or  of 
the  exaggerated  mood  reactions  presented  in  the  temperamental  subterfuge  ot 
cyclothymia,  or  of  those  manifold  metabolic  mimicries  grouped  under  the  ample 
category  designated  by  the  popular  misnomer  of  "neurasthenia" — under  wliat- 
ever  alias  the  organism  may  seek  to  elude  the  demand  most  vital  to  it,  at  the 
heart  of  the  neurosis  the  essential  situation  is  a  moral  revulsion. 

"This  revulsion  is  directed  unfailingly  against  the  admission  of  primary, 
egoistic,  organic,  unconscious  sexual  trends. 

"The  essential  moral  situation  present  in  the  neuroses,  the  inherent  conflict 
of  good  and  ill,  is  then  the  dominant  picture  in  these  disorders."* 

In  obsessions,  that  is,  in  the  states  in  which  the  patient  feels  com- 
pelled to  do  or  to  think  certain  things  against  his  will  as  it  were,  he 
takes  refuges  in  these  compulsive  acts  and  thoughts  from  the  painful 
conflict  of  ideas.  \'iz.,  by  counting  the  numbers  on  every  house  he 
passes,  the  patient  avoids  thinking  whether  he  should  replan  his  whole 
life  work.  etc.  In  Iiystcria  the  niental  conflict  is  converted  into  a  bodily 
change,  viz.,  the  action  of  an  arm  may  be  temporarily  suspended  and  we 
have  what  we  call  hysterical  paralysis :  or  the  action  of  the  eyes  is  held 
off,  and  we  call  it  hysterical  blindness  ;  of  the  ears,  it  being  hysterical 
deafness,  etc.  In  this  way  the  patient's  subconscious  attracts  his  atten- 
tion to  these  symjitoms  and  away  from  his  conflict.  In  the  paranoid 
states  the  patient  puts  his  attention  into  self-love,  self-admiration  (self- 
exaltation  )  and  thus  takes  his  attention  from  trying  to  improve  him- 
self so  as  to  gain  the  good  graces  of  others.  He  says  to  himself  they 
are  inferior,  they  fear  him  and  hence  plot  against  him.  Or,  and  he 
w^ill  not  admit  this  to  himself,  his  fear  is  born  of  desire  and  he  un- 
wittingly loves  them  to  such  an  extent  that  this  repressed  desire  makes 
him  afraid  of  them. 

In  anxiety  conditions  the  patient  emphasises  fears  and  apprehensions 
to  get  away  from  his  greater  difficulties:  so  also  in  cyclotJiyniia  or  the 
mild  elatcd-dcpresscd  reaction,  the  exaltation  causes  the  patient  to 
think  of  outside  objects  rather  than  his  inner  thoughts. 

The  neurasthenic  hides  his  conflicts  in  exaggerating  his  various 
normal  bodily  sensations  into  s\'mptoms.  Things  which  most  people 
pass  by  as  being  all  in  the  day's  course  of  events  he  magnifies  to  Gar- 
gantuan proportions  so  that  he  need  not  think  of  liis  complexes  or 
mental  conflicts. 

TREATMENT 

The  treatment  of  all  those  mental  disorders  listed  under  Section  A, 
that  is  those  associated  with  cortical  changes  and  general  medical  dis- 

*Dr.  Trigant  Burrow.     "Character  and  the  Neuroses." 


MKXTAL  DISORDERS  45 

eases,  falls  within  the  doniain  of  internal  medicine  and  can  be  studied 
there  in  detail.  In  the  main  the  princii)les  are  elimination  of  toxine, 
conserv3tion  of  the  vitality  and.  in  some  cases,  specific  ir.edicines  to 
cure  the  disease.  It  is  best  carried  out  in  a  psychiatric  clinic  which  is  a 
unit  of  a  general  hospital,  with  the  most  favorable  conduions  of  quiet- 
ness, kindly  nursing,  medical  and  psychiatric  care. 

The  treatment  of  the  outspoken  psychoses  of  Section  B — those  with- 
out underlying  medical  disease,  necessitates  in  many  cases  the  facilities 
of  a  hospital.  The  acute  period  of  disturbance  ideally  treated  should 
be  carried  out  with  the  patient  fully  isolated  from  the  sight  or  sound 
of  other  disturbed  patients,  and  there  should  be  an  abundance  of  intel- 
ligent and  kindly  nursing  and  medical  attendance. 

The  expense  of  all  this,  however,  precludes  such  conditions  for  most 
people  so  that  treatment  of  the  majority  of  cases  is  carried  out  in  in- 
stitutions with  varying  numbers  of  patients  to  a  ward.  Here  again  the 
keynote  of  treatment,  in  the  acute  stages  particularly,  should  be  kind- 
liness so  that  tlie  patient  may  come  through  his  illness  as  quickly  as 
possible,  and  have  onl}"  his  own  internal  difficulties  to  contend  with, 
these  being  quite  enough  without  anything  from  the  outside  being 
superimposed.  Too  many  of  our  institutions,  unfortunately,  are  run 
on  a  basis  of  penology,  rather  than  psycho-pathology;  that  is,  the  pa- 
tient is  punished  in  v^arious  ways,  including  physical  violence  (sub  rosa. 
of  course),  for  his  uncompromising  behavor.  It  is  unthinkable  to 
expect  a  set  of  ignorant,  poorly  paid  attendants  to  take  an  intelligent 
view  of  such  a  complicated  mental  reaction  as  insanity.  The  introduc- 
tion of  trained  nurses  and  better  salaries  and  hours  has  been  of  value 
in  this.  Perhaps  these  conditions  are  due  to  the  universal  avoidance  bv 
the  public  of  all  ideas  dealing  with  mental  disorder,  based,  it  mav  be, 
on  lack  of  knowledge  of  the  subject. 

After  the  disturbance  has  somewhat  quieted  dow^n,  occupation  is  of 
great  benefit  particularly  the  more  primitive  and  fundamental  hand 
work  such  as  the  manual  labor  and  interest  of  raisin^-  a  earden.  the 
gathering  and  cutting  of  wood  for  one's  own  fire,  the  making  of 
various  articles  of  wood  or  other  more  artistic  activities.  As  men- 
tioned in  the  discussion  of  Dementia  Precox,  many  such  elementary  and 
artistic  impulses  are  lying  latent  for  want  of  opportunity  in  psychiatric 
cases.  In  the  abundance  of  time  afforded  in  most  cases,  means  of  ar- 
tistic expression  may  be  developed  through  which  the  patient  may  main- 
tain his  equilibrium  during  the  rest  of  his  life.  In  all  cases  the  environ- 
ment should  radiate  normality  and  health  and  hope.  The  patient  who 
is  recovering  from  a  disturbance  is  often  in  a  particularly  sensit'ive 
slate  wherein  a  quiet  environment  with  much  outdoors  has  greatly  to  do 
with  aiding  final  recoverv. 

Finally  there  should  be  a  thorough  sifting  of  the  facts  of  the  ill- 
ness as  complete  as  the  patient  has  intuition-  for.     He  should  clarifv 


46  MENTAL  DISORDERS 

his  ideas  concerning  his  family,  his  relationship  to  each  member  of  it, 
the  factors  of  his  own  makeup,  his  predilections  and  capacities,  his 
opportunities  and  activities.  A  further  analysis  should  be  made 
whenever  possible  as  to  the  emotional  state  underlying  his  disorder, 
and  the  specific  causes  in  himself  of  this  actuating  emotional  state. 

REST    CURES. 

Rest  cures,  after  the  manner  of  Weir  Mitchell,  do  not  now  enjoy  the 
same  praise  that  they  did  when  first  introduced  a  generation  ago. 
Foremost  authorities  now  -consider  that  their  indiscriminate  use  in 
those  many  mild  cases  of  emotional  maladjustment  or  disorder,  called 
''nervous  breakdown,"  or  ''nervousness"  can  be  supplanted  with  a 
more  constructive  form  of  treatment. 

If  the  psychotic  situation  is  considered  to  have  come  about  because 
of  the  effect  of  the  environment's  acting  on  a  certain  type  of  individual, 
then  a  rest  from  this  environment  might  be  urged  to  have  certain  ad- 
vantages. But  to  return  the  patient  at  the  end  of  the  period  into  the 
same  environment,  without  making  any  radical  change  in  the  environ- 
ment, is  merely  setting  the  clock  back  a  few  days.  The  same  result 
will  inevitably  take  place  again. 

And,  moreover,  to  consider  again  the  action  of  the  environment  on  the 
person ;  some  permanent  effect  or  record  has  been  made  on  the  pa- 
tient by  this  environment.  The  patient  does  not  return  to  normal  by 
merely  removing  the  environment.  By  no  means.  Every  form  of 
matter  has  a  very  definite  property  of  memory  or  ability  to  retain 
impressions  or  records  made  upon  it,  and  most  especially  the  human 
nervous  system,  not  to  speak  of  those  subtler  entities,  the  emotional 
makeup  or  personality. 

One  might  argue  that,  since  life  consists  of  stimuli  received  trans- 
mitted into  acts  performed,  a  cutting  off  of  the  stimuli  reduces  the 
action,  and  hence  the  v/ear  and  tear  on  the  organism.  But  this  is  not 
Dossible ;  one  cannot  cut  off  all  stimuli.  We  receive  manv  stimuli 
from  our  surroundings,  especially  so  from  the  wards  of  a  hospital  or 
sanitarium.  And  apart  from  chese,  our  memory  itself,  as  mentioned 
above,  not  to  mention  our  ideals,  would  supply  us  with  stimuli  for  a 
longer  time  than  ever  was  contemplated  for  a  rest  cure.  And  to  deny 
an  outlet  to  these  stimuli  has  a  disturbing  and  destructive  effect  on  the 


organism. 


These  patients  suffer  already  from  too  little  life ;  from  the  fact  that 
they  cannot  convey  their  many  stimuli  into  actions.  They  are  already 
confused  or  disturbed.     This  is  the  meaning  of  maladjustment. 

Now,  if  instead  of  letting  the  patient  lie  idle  in  a  virtual  imprison- 
ment, the  time  were  taken  up  with  an  intelligent  and  painstaking  analy- 
sis of  the  whole  situation,  with  a  study  of  the  underlying  factors  and 
the  makeup  of  the  individual  himself,  the  patient  would  be  sent  back 


MiiATAL   DISOKDKKS  47 

into  the  damajiing  environment  a  new  and  different  person,  ihit 
this  is  rarely  done.  Only  the  most  superficial  statements  are  made  to 
the  patient. 

To  remove  the  stimuli  completely,  as  the  rest  cure  sets  as  its  goal, 
would  be  to  reduce  the  patient  to  a  state  of  such  vegetable  existence  as 
society  shudders  to  place  as  tlie  worst  punishment  upon  its  most 
horrible  criminals.  It  means,  at  the  least,  mental  annihilation  for  the 
period  of  the  "cure."  The  patient  then  has  to  recover  as  best  he  may 
from  this  annihilation.  Failing"  in  this,  and  happily  the  cure  does  in  many 
cases,  it  means  that  just  so  much  time  is  thrown  away  out  of  the  pa- 
tient's life.  For  here  is  the  point:  Constructive  work,  and  only  con- 
structive work,  will  change  either  the  environment  or  the  person,  and 
hence  the  situation. 

For  the  neuroses  and  milder  managable  psychoses  already  estab- 
lished or  about  to  be.  Psycho-analysis,  for  those  who  are  accessible,  is 
the  remedy  par  excellence,  and  the  only  real  remedy. 

Where  a  patient  has  the  least  speck  of  intelligence,  electrical  treat- 
ment for  the  neuroses  or  dilation  of  the  rectum  for  hysterical  attacks 
belong  to  the  same  archaic  stage  of  medical  superstition  as  the  burn- 
ing of  witches,  or  employing  amber  beads  or  horse  chestnuts  to  pre- 
vent arthritis. 

Psycho-analysis  is  a  setting  straight  of  mental  disorder,  by  tracing 
back  our  thoughts  to  the  deeper  motives  from  which  they  have  sprung 
and  thus  getting  at  what  really  does  actuate  us. 

The  best  way  to  do  this  is  through  the  utilization  of  associative 
material,  preferably  that  of  dreams,  by  taking  each  element  of  a 
dream  and  tracing  all  of  the  associations  in  our  mind  until  the  thought 
for  w'hich  this  stands  in  sym.bolic  form  is  found.  Every  dream,  then, 
is  found  to  contain  a  hidden  wish  which  for  some  reason  or  other  we 
would  not  admit  into  the  full  recognition — the  lime-light — of  our 
attention. 

Eventually  one  arrives  at  the  emotions  and  instincts  underlying  our 
behavior.  This  means  long  and  painstaking  work,  for  it  deals  with  the 
subtlest  yet  most  enduring  of  material,  namely,  the  personality :  and 
the  slightest  gain  means  an  advance  of  the  whole  person  into  greater 
development,  a  new  life. 

MEANS  OF  PREA'EXTIOX 
For  those  psychoses  of  organic  origin,  the  means  of  prevention  con- 
sist almost  completely  of  those  which  enter  into  general  medicine,  in- 
cluding hygiene,  early  treatment,  moderate  habits,  life  more  in  accord- 
ance with  the  demands  of  our  structure,  free  exercise  and  outdoor 
play. 

For  those  associated  with  industrial  diseases  there  remains  as  the 
only  remedy  the  general  country-wide  elimination  of  those  dangers 
from  trades. 


48  MENTAL  DISORDERS 

As  to  the  psychogenic  disorders,  or  disorders  of  emotion,  they  are 
as  indicated  in  the  discussion  of  Dementia  Precox,  of  social  origin ; 
that  is,  the  lack  of  consciousness  of  underlying  motives  and  emotions 
and  instincts  on  the  part  of  society  as  a  whole  results  in  such  treatment 
of  those  who  are  quasi-conscious  of  these  underlying  forces  that  the 
latter  take  refuge,  in  an  abortive  or  compromise  expression  of  what 
they  feel ;  the  abortive  expression  or  compromise  being  known  as  the 
mental  disorder. 

As  general  consciousness  of  these  facts  grows  in  society,  mental  dis- 
orders of  this  type  will  diminish  in  the  individual. 

Specifically,   a   much   freer,   more   individual,   more   personal,   more 
interesting  form  of  education  in  the  family  and  in  the  school,  of  the 
parents  and  of  the  children,  allows  a  completer,  truer,  sounder,  clearer 
mental  development  of  those  who  follow. 


REFERENCES 

Dr.  Adolf  Meyer — Xofcs  of  Clinics  in  Psycho-pathology. 
Dr.  Bernard  Hart — The  Psychology  of  Insanity. 

Fuudaniental  Conceptions  of  Dcnicntia  Praccox. 
British  Medical  Journal,  Sept.  29,  1906. 
Dr.   Trigant  Burrow — The  PsycJianalyst  and  the  Conininnity. — J.  A.  M. 

A.,  June  13,  1914,  \o\.  LXII,  pp.  1876-8. 
The  Meaning     of     Psychoanalysis. — Jour.     Abn. 

Psych.,  April -]\ fay,   191 7. 
llie   Origin   of  the  Incest  Azve — Psychoanalytic 
Review,  July,  1918,  \'ol.  A^,  Xo.  3. 
Rabindranath  Tagore — My    School. — In    the    Group    of    Essays    En- 
titled "Personalitv." 


